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A  TREATISE 


ORTHOPEDIC  SURGERY 


BY 


ROYAL  WHITMAN,  M.D. 


CLINICAL    LECTURER    AND    INSTRUCTOR    IN    ORTHOPEDIC    SURGERY    IN    THE    COLLEGE    OF    PHYSICIANS 

AND    SURGEONS    OP    COLUMBIA    UNIVERSITY,    NEW   YORK;    ASSOCIATE    SURGEON    TO    THE 

HOSPITAL  FOR   RUPTURED    AND   CRIPPLED;    ORTHOPEDIC  SURGEON  TO  THE 

HOSPITAL  OF  ST.    JOHN'S   GUILD. 

MEMBER    OF   THE    ROYAL    COLLEGE    OF   SURGEONS    OF    ENGLAND;    MEMBER    AND    SOMETIME    PRESIDENT 

OF    THE    AMERICAN    ORTHOPEDIC    ASSOCIATION;     CORRESPONDING    MEMBER    OF    THE 

BRITISH    ORTHOPEDIC    SOCIETY;    MEMBER    OF    THE    NEW    YORK    SURGICAL 

SOCIETY,  ETC.  • 


THIRD  EDITION,  REVISED  AND  ENLARGED 


ILLUSTRATED  WITH   FIVE  HUNDRED  AND   FIFTY-FOUR    ENGRAVINGS 


LEA   BROTHERS   &   CO. 

PHILADELPHIA   AND    NEW  YORK 

1907 


Entered  according  to  the  Act  of  Congress,  in  the  year  1907,  by 

LEA    BROTHERS    &    CO., 

in  the  Office  of  the  Librarian  of  Congress.     Ail  rights  reserved. 


DORNAN,    PRINTER, 


TO 
VIRGIL  P.  GIBNEY,  M.D.,  LL.D. 

THIS    VOLUME   IS   INSCRIBED 

AS    A    TOKEN    OF    FRIENDSHIP    ASSURED    BY    LONG    ASSOCIATION 

AND    OF    APPRECIATION    OF    HIS    EFFORTS 

FOR    THE    ADVANCEMENT    OF 

ORTHOPEDIC  SURGERY 


PREFACE  TO  THE  THIRD  EDITION. 


This  volume  presents  a  thorough  revision  and  amendment 
of  the  last  edition.  New  material  and  many  illustrations  have 
been  added,  and  the  author  trusts  that  it  fairly  represents  this 
department  of  medicine  at  the  date  of  issue. 

283  Lexington  Avenue,  New  York, 
December,  1906. 


FROM  THE  PREFACE  TO  THE  FIRST  EDITION. 


In  the  preparation  of  this  volume  it  has  been  the  purpose  of 
the  author  to  present  as  adequately  as  might  be  the  practice  of 
Orthopedic  Surgery  of  the  present  day. 

The  student  of  this  subject  is  especially  concerned  with  the 
mechanics  of  the  human  machine  with  its  development,  with  its 
capacity  at  different  periods  of  life  and  under  varying  conditions, 
and  with  those  affections  that  lead  to  deformity  or  that  otherwise 
impair  its  usefulness.  He  is  concerned,  moreover,  not  only  with 
the  local  and  immediate  effects  of  disease  or  disability,  but  with 
its  general  influence  upon  the  entire  mechanism,  and  with  its 
ultimate  consequences  as  well. 

Orthopedic  Surgery  occupies  a  broad  field  and  one  of  very 
great  and  general  interest.  Its  most  distinctive  advance  in  recent 
years  has  been  toward  the  prevention  of  deformity,  an  advance 
that  has  been  made  possible  by  the  better  understanding  of  its 
predisposing  and  exciting  causes.  As  a  natural  consequence, 
treatment  has  become  more  direct,  more  simple,  and  more  effec- 
tive.    It  has  been  the  purpose  of  the  author  to  emphasize  this 


vi  PREFACE 

aspect  of  the  subject,  which  is  of  the  greatest  importance  to  the 
general  practitioner,  who  so  often  has  the  opportunity  to  recognize 
disease  or  disabihty  in  its  incipiency,  when  its  progress  may  be 
checked  by  timely  treatment. 

He  has  endeavored  to  present  Orthopedic  Surgery  as  far  as 
possible  objectively,  and  in  a  manner  that  has  proved  acceptable 
to  students  and  practitioners  in  clinical  teaching.  Thus  the 
selection  of  each  subject  and  the  space  that  has  been  allotted  to 
it  has  been  determined  primarily  by  its  relative  importance  in 
the  actual  work  of  orthopedic  clinics.  He  has  been  at  some 
pains,  also,  to  outline  methods  of  examination,  to  explain  the 
phenomena  of  the  symptoms  and  so  to  describe  and  to  illustrate 
the  causes  and  effects  of  disease  and  disability  as  to  indicate,  in 
natural  secjuence,  the  principles  of  treatment;  but  the  particular 
methods  of  the  application  of  these  principles,  which  have  been 
described  in  detail,  are  always  those  that  have  been  tested  by 
personal  experience. 

Although  this  book  is  designed  particularly  for  students  and 
practitioners  of  medicine,  the  author  has  included  statistical  and 
other  data  which  he  hopes  may  prove  of  interest  to  his  fellow- 
workers  in  this  special  field. 

The  author  desires  to  express  his  obligation  to  the  gentlemen 
who  have  assisted  him  in  the  collection  of  statistics,  and  other- 
wise, whose  names  are  mentioned  in  the  text;  to  Dr.  L.  W.  Ely 
and  to  Mr.  W.  P.  Agnew  for  timely  photographs,  and  especially 
to  the  Trustees  of  the  Hospital  for  Ruptured  and  Crippled,  for 
the  facilities  that  have  been  afforded  him  in  the  preparation  of 
this  work. 


CONTENTS. 

i 
CHAPTER  I. 

TUBERCULOUS   DISEASE   OF   TUB   SPINE. 

PACK 

Description  — Pathology  — Etiology  — Statistics — General  prosinosis  — 
Symptoms — Physical  examination — Contour  and  flpxil)ility  of  the 
spine — Divisions  of  the  spine — Landmarks— The  ditterential  diagno- 
sis of  disease  in  the  lower,  middle,  and  upper  regions  of  the  spine — 
Treatment  by  horizontal  fixation  and  overextension — by  braces — 
by  plaster  jackets — by  other  means.  The  selection  and  adaptation 
of  treatment  for  disease  of  the  different  regions  of  the  spine.  The 
complications  of  tuberculous  disease  of  the  spine — Abscess — course 
—  symptoms  —  treatment.  Paralysis — course — symptoms — treat- 
ment. Forcible  correction  of  deformity — (Calot's  operation) — - 
Recurrence  of  Disease — Secondary  deformities — Recapitulation.  17 

CHAPTER  II. 

NON-TUBERCULOUS    AFFECTIONS     OF    THE    SPINE. 

Syphilis — Malignant  disease — Osteomyelitis,  acute  and  chronic — Actino- 
mycosis— Injury — Traumatic  spondylitis — Rhachitic  spine — Ty- 
phoid spine — Gonorrhoeal  arthritis  of  the  spine — Arthritis — Spon- 
dylitis deformans,  A^arieties — Osteitis  deformans — Spondylolisthesis 
— Relaxation  of  pelvic  joints — Pain  in  the  back — Neurotic  spine- 
Hysterical  spine — Sciatic  scoliosis — Disease  and  injury  at  the  sacro- 
iliac articulation .      .    126 

CHAPTER  III. 

'^^"^ LATER.\L    CURVATURE    OF   THE   SPINE. 


Description — habitual  and  fixed  deformity,  rotation  and  lateral  devia- 
tion. Pathology  — Etiology  — Statistics  — Varieties  — Distribution 
and  effects  of  deformity — Symptoms — Diagnosis — Prognosis — Pre- 
vention of  deformity — Desks,  chair.s — Principles  of  treatment- 
Treatment — by  exercises — general  exercises — heavy  exercises — 
special  exercises — Supports.  Forcible  correction  of  d  "fornu'ty — 
.\djuncts  in  treatment — Duration  of  treatment 149 

CHAPTER   IV. 

DEFORMITIES    OF   THE    SPINE    (CONTINUED).       DEFORMITIES    OF    THE    CHE.ST 
FirNCTIONAL    PATHOGENESIS    OF    DEFORAflTY. 

Variation  in  contour  of  the  spine — The  round  and  the  flat  back — Kyphosis 
— Lordosis — Treatment — Congenital    elevation    of    the    scapula — 


viii  CONTENTS 

PAGE 

Absence  of  vertebrte — Flat  chest — Pigeon  chest — Funnel  chest — 
Minor  deformities — CerAical  Ribs — Scapular  Crepitus — Absence  of 
ribs— Defective  formation  of  the  pectoral  muscles — Absence  or  de- 
fect of  the  clavicle — Acquired  luxation  or  subluxation  of  the  clavicle 
— As}Tnmetrical  development — Tables  of  height,  weight,  and  cir- 
cumference of  the  chest — -Functional  pathogenesis  of  deformity — 
(Wolff's  law)— Atrophy  of  bone — Hypertrophy  of  bone     ....   223 

CHAPTER  V. 

TUBERCULOUS   DISEASE   OF   THE   BONES   AND   JOINTS. 

Predisposition — Mode  of  infection — Latent  tuberculosis — Local  predis- 
position— Statistics— distribution  of  disease — location — side  affected 
— sex — age.  Pathology — Varieties  of  disease — synovial— arbores- 
cent syno\aal  fonn — hpoma  arborescens — rice  bodies — caries  sicca— 
Septic  infection— Progress  and  method  of  repair — Prognosis — 
Treatment^operative  and  mechanical — by  drugs — local  applica- 
tions— Iodoform  filling — X-ray — Active  and  passive  congestion — 
venous  stasis  (Bier's  treatment) 246 

CHAPTER  VI. 

NON-TUBERCULOUS  DISEASES  OP  THE  JOINTS. 

Syphilitic  disease  of  joints — Gonorrhoeal  arthritis — ^Other  forms  of 
infectious  arthritis — -Acute  epiphysitis — acute  osteomyelitis — Sub- 
acute osteomyelitis — Osteoarthritis  and  rheumatoid  arthritis — 
Varieties  —  Treatment  —  Still's  disease  —  Gout  —  Rheumatism  — 
HsmophiHa— Hsemarthrosis — Scorbutus^Charcot's  disease — Other 
forms  of  arthropathy — Anchylosis — Treatment 266 

CHAPTER  VII. 

TUBERCULOUS   DISEASE   OF   THE   HIP-JOINT. 

Pathology — Statistics^Symptoms — Physical  signs,  distortion,  apparent 
lengthening,  apparent  shortening.  Causes  of  distortion — Atrophy — 
Causes  of  actual  shortening — Measurements — Lovett's  table — ■ 
Kingsley's  table — Explanation  of  physical  signs — Differential  diag- 
nosis— Principles  of  treatment — The  traction  hip  brace — ^The 
Thomas  brace — The  plaster  bandage — Various  methods  of  reducing 
deformity — Comparison  of  methods  of  treatment — -The  long  liip 
splint^The  hip  splint  and  the  plaster  spica — Other  fornas  of  appa- 
ratus—Bilateral hip  disease — ^Hip  disease  in  infancy — Hip  disease 
in  adult  life — Abscess — statistics — treatment — Operative  treat- 
ment— exploration — excision — reduction  of  resistant  deformity — 
Prognosis,  mortality,  functional  results — Secondary  deformities 
of  hip  disease — Treatment — Final  results 298 

CHAPTER  VIII. 

NON-TUBERCULOUS   AFFECTIONS   OF  THE   HIP-JOINT. 

Statistics — Traumatisms  at  the  hip — Acute  infectious  arthritis  -Sub- 
acute arthritis — Spontaneous  dislocation — Gonorrha;al  arthritiy — 


CONTENTS 


PAGE 


Extra-articular  disease — Bursitis — Malignant  disease  at  the  hip-joint 

— Cysts  of  the  femur — Arthritis  deformans 398 

CHAPTER  IX. 

^^^ TUBERCULOUS    DISEASE   OP  THE   KNEE-JOINT. 

Pathology — Etiology — Statistics — Symptoms,  primary  and  secondary 
distortions — Shortening  and  lengthening — Diagnosis — Differential 
diagnosis — Treatment — Reduction  of  deformity — Forms  of  braces 
— Accessories  in  treatment — Extra-articular  disease — Abscess — 
Operative   treatment— arthrectomy — excision,    amputation — Prog  ■ 

['4     nosis — mortality — functional  results — General  conclusions      .      .      .   406 

CHAPTER  X. 

NON-TUBERCULOUS   AFFECTIONS   OF   THE   KNEE-JOINT. 

Injury  in  childhood — Acute  Synovitis — Chronic  Synovitis — Internal 
derangement  of  the  knee-joint — Prepatellar  bursitis — Pretibial 
bursitis — Injur}'  of  tibial  tubercle — Bursae  9>nd  cysts  in  the  pop- 
liteal region — Hyperplasia — Quiet  effusion — Acquired  genu  recur- 
vatum — Congenita]  genu  recurvatum — rudimentary  or  absent 
patella — Congenital  displacement  of  patella — Slipping  patella — 
Elongation  of  the  ligamentum  patella? — Snapping  knee — Congenital 
contraction  at  the  knee — General  contractions 434 

CHAPTER  XL 

>  DISEASES  AND   INJURIES   OF  THE  ANKLE-JOINT. 

Tuberculous  disease  — Pathology  — Etiology — Statistics  — Symptoms — 
Diagnosis — Treatment — Prognosis— Tuberculous  disease  of  the 
tarsus — Statistics — Treatment — Sprain  of  the  ankle — Chronic  sprain 
— Swelling  about  the  ankles — Tenosynovitis — Other  affections  of 
the  ankle-joint 450 

CHAPTER  XII 

DISEASES  AND  INJURIES  OF  THE  ARTICULATION  OF  THE 
UPPER  EXTREMITY. 

Tuberculous  disease  of  the  shoulder-joint — Pathology — Statistics — 
Symptoms — Treatment — Prognosis — Tuberculous  disease  of  the 
elbow-joint  —  Pathology  —  Statistics  —  Symptoms  —  Treatment  — 
Prognosis — Tuberculous  disease  of  the  wrist-joint — Symptoms — 
Treatment— Prognosis — Spina  ventosa— Periarthritis  at  the 
shoulder-joint — Chronic  bursitis  at  the  shoulder — Sprain  of  the 
wrist — Acute  and  chronic  tenosynovitis  at  the  wrist 466 

CHAPTER  XIII. 

DEFORMITIES    OF    THE    UPPER    EXTREMITY. 

Congenital  dislocation  of  the  shoulder — Obstetrical  paralysis  and  dis- 
location— Treatment — Operation   on    Brachial    plexus — Recurrent 


X  CONTENTS 

PAGE 

dislocation  of  the  shoulder — Congenital  deformities  of  the  elbow — 
Cubitus  valgus — Cubitus  varus — Subluxation  of  the  wrist. — Con- 
genital deformities  at  the  wrist — Club-hand — ^"arieties — Treat- 
ment— Club-hand  associated  witli  defective  development — Con- 
genital contraction  of  the  fingers — Webbed  fingers — Congenital  dis- 
placemejit  of  phalanges — Trigger  finger — Mallet  finger — Base-ball 
finger — Dupuytren's  contraction 482 

CHAPTER  XIY. 

COXGEXITAL    AXD    ACQUIRED    AFFECTIONS    LEADING    TO    GENERAL 
DISTORTTONS. 

Rhachitis — Etiology — Pathology — Symptoms,  deformities — Prognosis — 
Treatment — "  Late  rickets" — Chondrodystrophia — Infantile  scor- 
butus— Fragilitas  ossium — Osteomalacia — Osteitis  deformans  — 
Secondary  hypertrophic  osteo-arthropathy — Acromegalia       .      .      .   498 

CHAPTER  XV. 

CONGENITAL    DISLOCATION    OF    THE    HIP    AND    COXA    VARA. 

Congenital  dislocation  of  the  hip-joint — Statistics — Pathology — Etiology 
— Sj'mptoms,  unilateral,  bilateral — Anterior — Supracotyloid — Diag- 
nosis— Differential  diagnosis — Treatment — the  Lorenz  operation — 
Details  and  modifications — Prognosis — Treatment  of  older  subjects 
— Treatment  in  infancy — Palliative  treatment — The  open  operation 
Arthrotomy — the  intermediate  operation — secondary  osteotomy — 
The  Hoffa-Lorenz  operation — Review  of  treatment — Variations 
in  tieatment — Congenital  subluxation  of  the  hip — Snapping  hip 
— Coxa  vara — Pathology—  Etiology — Statistics — Symptoms,  uni- 
lateral; bilateral — Diagnosis — Treatment — mechanical — operative 
— Forcible  abduction — ^Osteotomy — Cuneiform — Linear — Fracture 
of  the  neck  of  the  femur — Traumatic  separation  of  the  epiphysis 
of  the  head  of  the  femur — Partial  epiphyseal  separation — Fracture 
in  adult  life — The  author's  treatment  for  complete — for  impacted — 
Coxa  valga 513 

CHAPTER  XVI. 

DEFORMITIES  OP  THE  BONES  OP  THE  LOWER  EXTREMITY. 

How-leg — Knock-knee — Statistics — ^Etiology — The  outgrowth  of  defor- 
mity— Genu  valgum — Description—Attitudes — Secondary  deform- 
ities—rGait — Unilateral  deformity — Pathology —Treatment — expec- 
tant— mechanical — operative — Geim  varum,  varieties — Symptoms 
— Treatirient — expectant —  mechanical —  operative — Ant(;rior  bow- 
leg— General  rheachitic  distortions 569 

CHAPTER  XVII. 

DISEASES   OP  THE   NKRVOILS   SYSTEM, 

Acute  anterior  poliomyelitis — Pathology —Etiology  —Statistics — Symp- 
toniH — Diagnosis — i^rognosis— Causes  of  Defcjrrnity    -Deformity  in 


CONTENTS 


PAGE 


various  regions — Subluxation — Retardation  of  growth — Principles 
of  Treatment — Treatment,  meclianical,  operative — Tendon  and  mus- 
cle transplantation — Arthrodesis — Nerve  grafting — Recapitulation  .   598 

CHAPTER  XVIII. 

DISEASES    OF   THE    NERVOUS    SYSTEM    (CONTIXUEd). 

Cerebral  paralysis  of  childhood — Description — Distribution — Etiology — 
Pathology — Symptoms — Congenital  paralysis — Acquired  paralysis 
— Hemiplegia — Paraplegia — Treatment,  mechanical,  operative — 
— Prognosis — Spastic  spinal  paraplegia — Progressive  muscular 
atrophy  — Varieties  — Symptoms  — Hereditary  ataxia  — Neuritis — 
Hysterical  and  functional  affections  of  the  joints — "  Hysterical" 
hip — Differential  diagnosis — "  Hysterical"  deformities — "  Hysteri- 
cal" club-foot — "Hysterical"  scoliosis — Neurotic  joints     ....   623 

CHAPTER  XIX. 

f CONGENITAL  AND  ACQUIRED  TORTICOLLIS. 

Description — Statistics — Congenital  torticollis — Etiology — HiPmatoma 
of  the  sternomastoid  muscle — Acquired  torticollis — "\^arieties — 
Acute  torticollis — Etiology — Symptoms — Diagnosis — Treatment  of 
chronic  torticollis — mechanical,  operative — Treatment  of  acute 
torticollis  — Spasmodic  torticollis  — Etiology  — Pathology — Treat- 
ment— Exceptional  forms  of  torticollis — paralytic — diphtheritic — 
cervical  opisthotonos,  rhachitic — ocular — psychical 642 

CHAPTER  XX. 

DISABILITIES    AND    DEFORMITIES    OF    THE    FOOT. 

General  description  of  the  foot  and  of  its  functions,  the  arches,  the  foot 
as  a  passive  support,  in  activity — Improper  postures — Movements 
— Function  of  the  muscles — Strength  of  the  muscles — The  foot  as  a 
mechanism — The  weak  foot  or  so-called  flat-foot — Description — 
Anatomy — Pathology — Etiology — Statistics — -Symptoms — Diagno- 
sis— Varieties — Weak  foot  in  childhood — Exceptional  forms — Treat- 
ment— Preventive — Exercises — Support — Construction  of  brace — 
The  rigid  weak  foot — Forcible  correction  of  deformit}'' — Sub.sequent 
treatment — Adjuncts  in  treatment — Operative  treatment       .      .      .   065 

CHAPTER  XXI. 

DISABILITIES  .\ND  DEFORMITIES  OF  THE  FOOT  (CONTINUED). 

The  hollow  foot — Varieties  and  treatment — Anterior  metatarsalgia — 
Morton's  neuralgia — Etiology — Treatment — Achillobursitis — Strain 
of  the  tendo  Achilles — Calcaneobursitis — Plantar  neuralgia — Ery- 
thromelalgia — Intermittent  limp — Hallux  rigidus — Painful  great 
toe — Hallux  varus^Pigeon  toe — Metatarsus  varus — Hallux  valgus 
— Hammer  toe — -Overlapping  toes — Fracture  of  metatarsus — Exos- 
toses— Displacement  of  the  peronei  tendons — Shoes,  effects  of 
improper  shoes — Demonstration  of  the  proper  shoe — ^Socks  .      .      .716 


xii  CONTENTS 

CHAPTER  XXII. 

DEFORMITIES    OF   THE    FOOT. 

PAGE 

Talipes — Description — Varieties — Statistics  of  talipes,  congenital  and 
acquired — Relative  frequencj-  of  the  different  varieties — Congenital 
talipes — Etiology — -\natomy — S^^nptoms — Principles  of  treatment 
of  infantile  club-foot — Treatment — mechanical — b}^  plaster  band- 
age— by  braces — restoration  of  function — supervision — -Treatment 
in  older  subjects — forcible  manual  correction — tenotomy — Wolff's 
treatment,  reduction  of  deformity  by  wrenches — Phelps'  operation 
— Operations  on  the  bones — Astragalectomy — Osteotomy — Me- 
chanical treatment — Other  varieties  of  congenital  talipes — varus 
— equinus  — calcaneus  — valgus  — equinovalgus  — calcaneovalgus  — 
calcaneo varus — equinoca\'us — valgocavus — Congenital  talipes  as- 
sociated with  defective  development — with  absence  of  fibula — with 
absence  of  tibia — with  defective  formation  of  the  foot — Constricting 
bands — Congenital  amputation — Congenital  oedema — Spina  bifida 
and  talipes 752 

CHAPTER  XXIII. 

DEFORMITIES  OF  THE  FOOT  (CONTINUED). 

Acquired  talipes — Etiology — Diagnosis — ^Talipes  equinus — Description — 
— Etiology  —  Symptoms  —  Treatment  —  mechanical  —  operative — 
Talipes  calcaneus — Description,  development  of  deformity — Symp- 
toms— Treatment — mechanical,  operative — Willet's  operation — The 
author's  operation — Talipes  calcaneovarus  and  calcaneovalgus — 
Talipes  equinovarus  and  talipes  equinovalgus — Talipes  valgus — • 
Traumatic  valgus — Other  varieties  of  acquired  talipes — Tendon 
transplantation  in  the  treatment  of  paralytic  talipes — Tendon 
transplantation  and  arthrodesis — Tendon  splicing — -Artlu'odesis 
and  other  procedures 813 


ORTHOPEDIC    SUEGEEY. 


CHAPTER  I. 

TUBERCULOUS  DISEASE  OF  THE  SPINE. 

Synonym. — Pott's  disease. 

Pott's  disease  is  a  chronic  destructive  process  of  the  bodies 
of  the  vertebra.  The  spine  bends  at  the  weakened  point,  and 
the  upper  part,  sinking  downward  and  forward,  throws  into 
relief  one  or  more  of  the  spinous  processes  at  the  seat  of  the  dis- 
ease; thus  an  angular  posterior  projection  is  formed.  It  is 
called  Pott's  disease  because  such  deformity,  accompanied  by 
pain  and  sometimes  by  paralysis,  was  first  described  accurately 
by  Percival  Pott,  in  1779.  Angular  deformity  is,  however,  simply 
the  evidence  of  destruction  of  a  portion  of  the  anterior  part  of 
the  vertebral  column.  Thus  it  might  be  the  result  of  fracture, 
or  of  the  erosion  of  an  aneurism,  or  of  malignant  disease,  or 
syphilis,  or  other  pathological  process;  but  deformity  from  such 
causes  is  not  now  included  under  Pott's  disease,  nor  is  the  term 
now  synonymous  with  deformity.  In  the  modern  sense  it  sig- 
nifies tuberculous  disease  of  the  bodies  of  the  vertebrae,  of 
which  the  early  symptoms  may  be  detected  and  of  which  the 
deforming  effects  may  be  checked  and  even  prevented  by  proper 
treatment. 

The  compression  and  collapse  of  the  affected  parts  cause  the 
characteristic  angular  projection  at  the  seat  of  the  disease 
(Fig.  2).  If  one  vertebral  body  is  destroyed  the  projection  will 
be  sharp;  if  several  are  implicated  it  will  be  less  angular,  and 
if  one  side  of  a  body  breaks  down  before  the  otlier  there  may 
be  a  lateral  as  well  as  a  posterior  distortion. 

The  size  of  the  deformity  and  its  effect  upon  tlie  individual 
depend  in  great  degree  upon  its  situation.  If  the  disease  is 
at  either  extremity  of  the  spine  the  angular  projection  is  slight 
because  the  area  of  the  spine  directly  involvetl  in  the  deformity 

2 


18 


OB  TH  OPE  DIG  SURGERY 


is  small  compared  to  that  which  is  free  from  disease  (Fig.  5). 
But  if  the  centre  of  the  spine  is  affected  the  opportunity  for 
deformity  is  great,  because  the  entire  column  may  enter  into 
the  formation  of  the  angular  kyphosis.  In  such  cases  the  internal 
organs  are  compressed  and  the  effect  upon  the  vital  mechanism 
is  disastrous-  (Fig.  23). 

Pott's  disease,  as  contrasted  with  tuberculosis  of  other  bones 
and  joints,  is  peculiar  in  its  inaccessibility;  in  its  proximity  to 
important  parts,  the  vital  organs  in  front 
and  the  spinal  cord  behind.  Finally,  in 
that  the  effects  of  disease  and  deformity 
influence  in  much  greater  degree  the  entire 
mechanism  of  the  body. 

Pathology. — The  minute  changes  that 
characterize  tuberculosis  of  bone  in  gen- 
eral are  described  in  Chapter  V. 

The  first  indication  of  the  disease  is 
usually  found  in  the  anterior  part  of  a 
vertebral  body  just  beneath  the  fibroperi- 
osteal  layer  of  the  anterior  longitudinal 
ligament.  From  this  point  the  granulation 
tissue  advances  along  the  front  of  the  spine, 
and  following  the  course  of  the  bloodvessels 
it  invades  the  adjacent  vertebral  bodies. 
In  other  instances  the  process  may  begin 
in  the  interior  of  a  vertebral  body,  most 
often  in  several  minute  foci  near  the  upper 
or  lower  epiphysis.  These  coalescing,  gradu- 
ally enlarge,  forming  a  cavity,  surrounded 
for  a  time  by  unbroken  cortical  substance, 
which  finally  collapses  under  the  pressure 
lumbar  vertebra;— with  the  of  the  supcrincumbent  Weight.  Occasiou- 
re^«uiting  deformity.    (M6-    ^jj^    ^^^    discasc     advauccs    beneath     the 

anterior  ligament  without  implicating  deeply 
the  su})stance  of  the  bone— a  form  of  tuberculous  periostitis, 
"spondylitis  superficialis." 

The  intervertebral  disks  appear  to  offer  some  resistance  to 
the  extension  of  the  disease  from  one  vertel)ra  to  another,  but 
when  the  bone  is  destroyed  on  either  side  they  quickly  disin- 
tegrate and  disappear.  The  posterior  part  of  the  spinal  column 
usually  remains  free  from  disease,  with  the  exception  of  the 
pedicles  and  articulations  that  may  be  in  direct  contact  with  it. 


Destruction  of  the  bodies 
of  the  first,  second  and  third 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


19 


In  rare  instances  the  process  may  begin  in  a  lamina  or  spinous 
process,  or  in  one  of  the  small  joints;  but  such  forms  of  local 
tuberculosis  could  hardly  be  classed  as  Pott's  disease. 

The  course  and  outcome  of  the  disease  depend  upon  its  type. 
In  one  instance  the  area  of  primary  infection  is  small  and  the 


Fig.  2 


Pott's  disease. 

local^resistance  is  sufficient  to  check  its  further  progress,  so  that 
cure  without  deformity  may  follow.  In  another  the  disease 
is  inactive  and  the  granulation  tissue  undergoes  a  fibroid  trans- 
formation or  becomes  ossified.  In  such  cases  deformity  mav 
appear  and  slowly  increase,  practically  without  symptoms. 
In   most  instances,   however,   the  infected  granulations  atlvance 


20  OB  TH  OPE  Die  S  UB  OEBT 

more  rapidly,  destroying  the  bone  or  other  tissue  with  which 
they  come  in  contact.  There  is  the  usual  retrograde  metamor- 
phosis to  cheesy  degeneration,  and  very  frequently  liquefaction 
and  abscess  forruation  follow. 

As  a  nde,  in  those  cases  of  moderate  severity  that  come  to 
autopsy  during  the  progressive  stage  of  the  disease,  one  finds, 
on  di\^ding  the  thickened  tissues  in  front  of  the  spine,  a  cavity 
the  walls  of  which  are  lined  with  granulation  tissue  in  various 
stages  of  degeneration,  and  containing  puriform  fluid.  The 
adjoining  vertebral  bodies  present  a  worm-eaten  appearance, 
and  one  or  more  of  them  is  partially  destroyed.  Small  frag- 
ments of  necrosed  bone,  "bone  sand,"  may  be  recognized,  and 
occasionally   sequestra   of   considerable   size   are   present. 

If  the  disease  begins  in  the  interior  of  a  vertebral  body  it  may 
extend  backward  as  well  as  forward,  and  forcing  its  way  into 
the  vertebral  canal  it  may  press  upon  the  spinal  cord,  and 
even  before  deformity  is  apparent  involve  its  coverings,  thus 
causing  paralysis  of  the  parts  below.  Less  often  pressure  on  the 
cord  may  be  due  to  the  presence  of  an  abscess  or  to  a  projecting 
fragment  of  bone.  The  calibre  of  the  spinal  canal  may  be  con- 
stricted somewhat  by  the  pressure  of  the  superincumbent  weight 
upon  the  softened  and  thickened  tissues  at  the  seat  of  disease ;  but, 
as  a  rule,  its  capacity  is  not  directly  lessened  by  the  angular  dis- 
tortion, nor  does  the  degree  of  deformity  directly  influence  the 
frequency  of  paralysis. 

Although  the  disease  may  begin  in  multiple  primary  foci  of 
infection  over  an  extended  area,  or  in  two  or  more  distinct  re- 
gions of  the  spine  simultaneously,  yet  clinical  observation  seems 
to  show  that  it  is,  in  most  instances,  originally  confined  to  one 
or  two  adjacent  bodies.  From  this  central  point  it  may  extend 
in  either  direction  until  half  the  spine  is  implicated;  but  in  ordi- 
nary cases  the  final  area  of  deformity  and  rigidity  shows  that 
from  three  to  six  bodies  are  more  or  less  involved  before  cure  is 
established. 

If  the  disease  is  limited  in  extent,  the  eroded  surfaces  of  the 
adjoining  verteljra;  may  come  into  direct  contact;  but  if  several 
vertebral  })odies  have  been  destroyed,  the  upper  portion  of  the 
spine  as  it  sinks  downward  is  often  displaced  backward,  so  that 
the  anterior  aspect  of  one  or  more  of  the  upper  segments  may 
be  apposed  to  the  superior  surface  of  the  first  body  of  the  lower 
section  (Fig.  3).  Less  often  there  may  be  forward  displace- 
ment of  the   upper  part  u})on   the  lower   (Fig.    1). 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


21 


At  all  stages  of  the  disease  resistance  to  its  progress  antl  eft'orts 
at  repair  are  evident  in  the  affected  parts.  When  this  resist- 
ance overbalances  the  tendency  to  degeneration  its  progress  is 
checked. 


Fig.   3 


Fig.   4 


tO@ 


iM> 


Destruction  of  the  bodies  of  the  third, 
fourth,  fifth,  ."sixth,  and  seventh  dors^al  ver- 
tebne;  partial  destruction  of  tlirec  others. 
(  M6nard.) 


The    deformity   corrected,    .show-ing    the 
area  of  the  destructive  process.     (Menard.) 


Repair  is  accomplished  occasionally  by  contact  and  solid 
union  of  the  adjoining  surfaces  of  softened  bone;  but  usually 
the  anchylosis  is  in  part  fibrous,  in  part  cartilaginous,  and  in 
part  bony,  and  this  union  may  be  further  strengthened  by  a 
callous  formation  from  the  thickened  tissues  about  the  seat  of 
the    disease.     In    many    instances    the    articular    processes,    tlie 


22  ORTHOPEDIC  S UB GEB T 

pedicles,  and  laiuintp  become  anchylosed  before  repair  has  ad- 
vanced appreciably  in  the  anterior  portion  of  the  column. 

Cure  may  be  absolute,  as  when  no  vestige  of  the  disease 
remains;  it  may  be  practically  assured,  as  when  the  diseased 
products  undergo  calcareous  degeneration  and  are  shut  in  by 
a  layer  of  solid  bone.  In  other  instances  the  disease  becomes 
quiescent  or  but  slowly  advances,  showing  its  presence  by  ex- 
acerbations of  pain  or  by  the  formation  of  an  abscess  long  after 
active   symptoms  have  ceased. 

Etiology. — The  etiology  of  tuberculosis  of  the  spine  does  not 
differ  from  that  of  tuberculosis  of  other  bones;  the  subject  is 
considered  in    Chapter  V. 

Relative  Frequency. — Tuberculosis  of  the  spinal  column  is 
more  common  than  of  any  other  single  bone  or  joint,  as  might 
be  expected  from  its  greater  area.  This  is  illustrated  by  the 
statistics  of  tuberculous  disease  treated  in  the  out-patient  depart- 
ment of  the  Hospital  for  Ruptured  and  Crippled  during  a  period 
of  twenty  years,  1885-1904. 

Tuberculosis  of  the  spine     .......        4299   cases. 

of  the  hip 3329       " 

"  of  other  joints  inclusive  ....        3222       " 

Total 10,850 

Also  by  statistics  of  the  Boston  Children's  Hospital  for  a  similar 
period,  1869-1888: 

Tuberculosis  of  the  spine      .......         1864  cases, 

"  of    the   hip,    knee,  ankle,  shoulder,    elbow,    and 

wrist  combined    ......        1856       " 


Total 3720 

Age. — Pott's  disease,  although  far  more  frequent  in  the  middle 
period  of  childliood,  from  the  tliird  to  the  tenth  year,  may  occur 
at  any  time  from  earliest  infancy  to  extreme  old  age. 

In  a  series  of  12.59  consecutive  cases  of  tuberculosis  of  the 
spine  collected  from  the  records  of  the  out-door  department 
of  the  Hospital  for  Ruptured  and  Crippled,  analyzed  by  Drs.  R. 
T.  Frank  and  C.  Gunter,  the  ages  of  the  patients  at  the  supposed 
time  of  onset  of  tlie  di.sease  appeared  to  be  as  follows: 


LeHH  than  1  year    . 
Between    1  and    2  year> 

-.i     "      5  " 

0     "     10  " 

11     "    20  •• 
21     "     30 

31     "    60  •■ 
Over  50      " 


38  ■=     3.1  per  cent 

176  =  14.2  " 

627  --  50.2  " 

234  =  18.3  " 

89  =    7.2  " 

43  =    3.5  " 

31  =    2.P  •• 

11  =    0.8  " 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


23 


The  youngest  patient  was  two  months  old,  the  oldest  seventy- 
one  years. 

Thorndike/  of  Boston,  from  the  records  of  the  Boston  Chil- 
dren's Hospital  for  thirteen  years,  1SS3  to  1896,  collected  115 
cases  of  tuberculosis  of  the  spine  in  children  of  two  years  or  less. 
Seven  of  these  were  less  than  six  months,  and  twenty  were  under 
one  year  in  age. 

Howard  Marsh^  has  called  attention  to  Pott's  disease  of  the 
aged,  and  cites  three  cases  in  subjects  of  sixty  or  more  years 
of   age. 

Sex. — Sex  exercises  comparatively  little  influence  on  the  lia- 
bility to  disease  of  this  region.  Of  3797  cases  collected  by  Mohr, 
Gibney,  Fischer,  Taylor,  and  Bradford  and  Lovett,  quoted 
by  Hoffa,  2045  were  in  males  and  1752  were  in  females.  Of 
1367  cases  collected  by  Frank  and  Gunter,  708  (52  per  cent.) 
were  in  males  and  659  (48  per  cent.)  were  in  females;  and  in 
2455  cases  tabulated  by  Knight,  1329  were  in  males  and  1126 
in  females.  Of  these  combined  cases  from  the  Hospital  for 
Ruptured  and  Crippled,  3822  in  number,  53.2  per  cent,  were 
in  males  and  46.8  per  cent,  in  females. 

The  Situation  of  the  Disease.— The  dorsolumbar  section  of 
the  spine  is  most  often  affected.  Cervical  disease  is  compara- 
tively infrequent. 

In  the  series  of  1355  cases  from  the  records  of  the  Hospital 
for  Ruptured  and  Crippled,  the  attempt  was  made  to  locate 
the  origin  of  the  disease  by  the  most  prominent  spinous  process 
in  the  tracino-.     The  followino-  are  the  conclusions: 


First    . 

Second 

Third  . 

Fourth 

Fifth   .  . 

Sixth  . 

Seventh 

Eighth 

Ninth 

Tenth 

Eleventh 

Twelfth 


Cervical. 

Dorsal. 

Lumbar. 

Lumbosacral 

3 

26 

94 

13 

3 

43 

96 

15 

42 

64 

20 

46 

57 

13 

49 

6 

22 

76 

24 

82 
97 
92 

110 
71 

120 

100 


854 


317 


13 


No  deformity,  cervical    .........       2 

"  "  dorsal        .........      31 

lumbar 22 


Disease  in  two  rea:ions  of  the  spine 


55 
16 


1  Transactions  American  Orthopedic  Association,  1896,  vol.  ix.      -  Ibid.,  1891,  I'ol.  iv. 


24 


ORTHOPEDIC  SURGERY 


Similar  statistics  are  recorded  by  Julius  Dollinger/  of  Budapest, 
of  700  cases  of  Pott's  disease.  Of  these  the  situation  of  the  pri- 
mary disease  could  be  ascertained  in  53S.  In  63  the  disease 
was  of  the  cervical,  in  321  of  the  dorsal,  and  in  154  of  the 
lumbar  remon. 

The  relative  frequency  of  disease  of  the  different  dorsal  and 
lumbar  vertebrne  was  as  follows: 


First    . 

Second 

Third  . 

Fourth 

Fifth   . 

Sixth  . 

Seventh 

Fjghth 

Ninth 

Tenth 

Eleventh 

Twelfth 


Dorsal. 

Luvibar. 

6 

59 

7 

37 

12 

31 

10 

17 

19 

10 

17 

33 

36 

36 

43 

38 

64 

154 


The  proportionate  length  of  the  different  sections  of  the  spine 
at  the  age  of  five  years  is,  according  to  Disse:^ 


Cervical 

Dor.-al 

Lumbar 


20.2 
45.6 
34.2 


100.0 


If  this  be  contrasted  with  the  percentjage  of  the  cases  of  disease 
of  each  section,  it  will  show  that  the  frequency  of  the  disease 
in  the  different  regions  of  the  spine  does  not  correspond  to  the 
area,  as  has  been  suggested,  but  that  it  is  proportionately  much 
less  frequent  in  the  cervical  and  much  more  frequent  in  the  dor- 
sal region. 

DoUinfier.  Frank  and  Gunter.  Area. 


Cervical 

11.7  per  cent. 

Cervical 

.      7.7  per  cent.— 20.2 

Dorsal 

.      59.6   "      " 

Dorsal 

.  66.4    "     "     —45.6 

Lumbar 

.      28.6    "       " 

Lumbar 

.  25.6   "     "     —34.2 

This  may  be  explained  apparently  by  the  greater  strain  to 
which  the  middle  and  lower  parts  of  the  spine  are  subjected,  as 
well  as  by  the  relative  proportion  of  cancellous  tissue  which  offers 
the  opportunity  for  infection. 

It  may  be  noted  in  this  connection  that  the  proportionate 
length  of  the  sections  of  the  spine  changes  somewhat  with  the 
age,  as  is  illustrated  by  the  following  table,  the  scale  being  1000:^ 

'  Die  BcharidliinK  der  TuberouloHcn  WirbelontKuridung,  Slut-tKart,  1898. 

'■'  Skclctlehrc,  1890. 

"  Moser,  in  Yoachimsthal's   Uaiidb.  der  Orth.  (Jliir.,  1905,  i).  521. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  25 

Cervical.  Thoracic.        Lumbar. 

At  birth 240  490  200 

Three  years 214  479  306 

Five  years 200  486  308 

Eleven  years 209  500  290 

Fourteen  years 216  500  284 

Adult 195  482  323 

Prognosis. — The  prognosis  in  tubercnlous  disease  is  discussed 
in  Chapter  V.  Pott's  disease  is  the  most  dangerous  of  all  the 
tuberculous  affections  of  the  bones  or  joints,  as  would  be  ex- 
pected from  the  relative  importance  of  the  structure  affected 
and   of  the   parts  lying  in   contact   with   it. 

It  is  evident  also  that  the  degree  of  deformity  and  its  situa- 
tion have  a  direct  influence  on  the  prognosis.  In  disease  of 
either  extremity  of  the  spine  the  direct  deformity  is  insignifi- 
cant and  the  secondary  effect  upon  the  trunk  is  slight. 

In  the  typical  "hump-back"  deformity,  however,  the  con- 
tents of  the  thorax  and  abdomen  are  necessarily  compressed; 
the  bloodvessels  are  distorted,  and  the  calibre  of  the  aorta,  which 
is  more  directly  affected,  is  often  much  diminished;  respiration 
is  made  difficult,  and  the  circulation  is  impeded;  as  a  conse- 
quence, the  heart  is  usually  hypertrophied  and  valvular  insuffi- 
ciency is  not  infrecjuent.  Thus  the  vital  functions,  which  are 
carried  on  at  a  disadvantage  even  under  favorable  conditions, 
become  impossible  under  the  added  strain  of  unfavorable  sur- 
roundings, overwork,  or  disease.  It  is  a  matter  of  common 
observation  that  few  of  those  who  are  markedly  deformed  reach 
old  age.  On  the  other  hand,  it  may  be  assumed  that  slight 
deformities,  or  those  which  do  not  as  directly  interfere  with  the 
vital  functions',  exercise  but  little  influence  upon  the  future  well- 
being  of  the  patient. 

Although  the  absolute  mortality  of  Pott's  disease  cannot  be 
accurately  estimated,  it  may  be  stated  that  at  least  20  per  cent, 
of  all  patients  die  during  the  progress  of  the  disease  and  within 
a  few  years  after  its  onset,  from  causes  directly  or  indirectly 
dependent  upon  the  local  lesion.  Some  of  these  die  from  gen- 
eral dissemination  of  the  tuberculous  infection  and  tuberculous 
meningitis;  some  from  exliaustion  following  septic  infection 
and  long-continued  suppuration,  or  from  amyloid  degeneration 
of  the  internal  organs;  some  from  tuberculosis  of  the  lungs,  and 
many  from  intercurrent  affections  that  are  fatal  because  of  the 
devitalizing  influence  of  the  disease  and  its  complications. 

The  prognosis  of  Pott's  disease  in  the  individual  case  is  in- 
fluenced by  many  considerations.     In   one  instance  the  family 


26  ORTHOPEDIC  SJJRGEBT 

history  is  good,  the  surroundings  are  favorable,  the  patient  is 
in  good  condition,  and  the  disease  is  in  the  early  stage;  one  is 
then  inclined  to  look  upon  it  as  an  accident,  and  hardly  considers 
the  possibility  of  a  fatal  termination;  while  in  another  case  the 
weakness  and  undervitalization  of  the  body  are  so  evident  that 
the  affection  of  the  spine  seems  but  an  incident  of  a  general  de- 
generation. 

Symptoms. — The  most  distinctive  sign  of  Pott's  disease  is 
deformity.  At  an  early  stage  of  the  process  there  may  be  but 
a  slight  irregularity  in  the  contour  of  the  spine,  and  if  several 
adjacent  vertebral  bodies  are  affected  the  projection  may  be 
somewhat  rounded  in  outline;  but  as  compared  with  other  de- 
formities of  the  spine,  that  of  Pott's  disease  is  characteristically 
angular,  and  as  its  cause  is  loss  of  substance,  its  formation  is 
accompanied  by  and  must  have  been  preceded  by  the  symptoms 
of  bone  disease. 

Deformity  is  thus  the  evidence  of  a  destructive  process  that 
may  have  existed  for  weeks  or  months  even,  and  only  by  its  early 
recognition  can  the  ideal  result — the  prevention  of  deformity — 
be  attained.  The  spine  which,  although  weak,  is  still  straight 
may  be  held  straight;  but  when  the  deformity  is  present,  it  can 
be  remedied  only  in  part,  and  it  may  be  difficult  even  to  check 
its  further  progress.  For  as  the  upper  segment  of  the  spine 
sinks  forward  and  downward,  the  influences  of  compression  and 
attrition  increase  the  activity  of  the  local  process  and  aggravate 
its  effects. 

For  many  years  angular  deformity  was  thought  to  be  the  es- 
sential sign  of  Pott's  disease,  and  even  now  the  fact  is  not  gener- 
ally recognized  that  the  detection  of  tuberculous  ostitis  of  the 
spine  in  the  early  stage  is  both  possible  and  easy,  if  one  will 
apply  the  same  methods  that  serve  for  the  diagnosis  of  other 
affections  not  attended  by  a  symptom  so  obvious  as  external 
deformity.  It  is  to  such  aj)plication  of  the  principles  of  differ- 
ential diagnosis  that  attention  is  called. 

The  spine  is  the  chief  support  of  the  body,  possessing  a  free 
moljility  that  acconiiiKKJates  it  to  every  movement  of  the  trunk 
and  to  every  motion  of  the  limbs  even.  It  is  evident,  therefore, 
that  the  symptoms  of  a  destructive  disease  must  be  pain,  weak- 
ness, and  impairment  of  normal  motion.  Motion  and  support 
are  not,  however,  the  only  functions  of  the  spine;  it  contains 
the  spinal  cord,  from  which  branch  the  nerves  that  supply  the 
organs  and  members  of  tlic  liody.     This  may  be  implicated  ^i 


TUBERCULOUS  DISEASE  OF  THE  SPINE  27 

an  early  stage  of  the  affection  and  the  sudden  onset  of  paralysis 
may  overshadow  the  symptoms  of  the  original  disease.  In 
other  instances  the  tumor  of  an  abscess — one  of  the  common 
accompaniments  of  tuberculous  disease  of  the  bone — may  in- 
terfere with  the  functions  of  important  parts  lying  in  the  neighbor- 
hood of  the  spine,  and  peculiar  sjTiiptoms,  due  to  this  cause, 
may  attract  attention  before  the  primary  disease  is  suspected. 
Such  symptoms  may  be  misleading  and  it  is  well,  therefore,  to 
consider  them  apart  from  those  that  indicate  the  primary  effect 
of  the  disease  upon  the  spine,  considered  as  an  elastic  support. 
These  direct  symptoms  usually  precede  and  always  accompany 
the  secondary  or  complicating  symptoms,  and  upon  them  the 
diagnosis  depends. 

The  primary  and  diagnostic  symptoms  of  Pott's  disease  may 
be  classified  as  follows: 

(a)  Pain. 

(6)  Stiffness. 

(c)  Weakness. 

{d)  Awkwardness.  -^ 

{e)  Deformity, 
(a)  Pain. — At  first  thought,  one  might  expect  the  pain  of  Pott's 
disease  to  be  localized  at  the  affected  vertebrae,  and  to  be  accom- 
panied by  sensitiveness  to  pressure  or  even  by  infiltration  and 
swelling  of  the  neighboring  tissues;  but  it  will  be  remembered 
that  the  bodies  of  the  vertebrae  are  in  the  interior  of  the  trunk 
practically  speaking,  as  near  to  its  anterior  as  to  its  posterior 
surface  (Fig.  9),  and  that  the  products  of  the  disease  pass  down- 
ward and  forward,  rarely  backward.  Thus  sensitiveness  to 
pressure  on  the  projecting  spinous  processes  is  unusual,  and 
palpation,  except  in  the  cervical  region,  is  of  comparatively  little 
diagnostic  value. 

The  pain  of  Pott's  disease  is  not  localized  in  the  back,  in  the 
neighborhood  of  the  disease,  because  the  filaments  that  supply 
the  bodies  of  the  vertebrae  are  insignificant  parts  of  nerves  that  are 
distributed  to  distant  points — to  the  head,  to  the  limbs,  to  the 
front  and  sides  of  the  trunk — and  to  these  parts  the  pain  is  re- 
ferred; thus  "ear-ache"  or  "stomach-ache"  or  "sciatica"  may 
be  symptomatic  of  Pott's  disease.  The  pain  of  Pott's  disease 
is  by  no  means  constant;  it  is  induced  by  jars  or  by  sudden  or 
unguarded  movements.  It  is  often  worse  at  night,  when,  after 
the  relaxation  of  the  muscular  tension  that  has  protected  the 
part,  the  unconscious  movements  during  sleep  cause  discomfort 


28  OB THOPEDIC  SUBGEEY 

or  pain,  and  the  child  moans  in  its  sleep,    or    is  restless,  and 
sometimes  it  ^Yakes  with  a  cry — "nip-ht  cry." 

(h)  Impairment  of  Function  or  Loss  of  Normal  Mobility:  Stiffness. 
— Stiffness  of  the  spine  is  in  part  voluntary,  in  the  sense 
that  the  patient,  adapts  his  moyements  and  attitudes  to  the  disease 
and  pain — in  order  to  ayoid  as  far  as  possible  strain  and  jar — 
but  the  essential  and  characteristic  stiffness  of  Pott's  disease 
is  caused  bv  the  involuntary  muscular  pension  and  contraction 
of  the  muscles  about  the  seat  of  disease.  This  reflex  muscular 
spasm  varies  in  degree,  according  to  the  state  of  the  underlying 
disease.  It  may  fix  the  spine  or  it  may  be  evident  only  at  the 
extremes  of  motion,  but  it  is  always  present,  preceding 
deformity  and  accompanying  it  until  cure  is  established;  thus 
it  is  the  most  important  of  the  diagnostic  symptoms  of  Pott's 
disease. 

(c)  Weakness. — As  the  disease  affects  the  most  important 
support  of  the  body,  it  is  a  direct  as  well  as  an  indirect  cause 
of  weakness,  and  the  more  vulnerable  the  spine  the  more  pro- 
nounced is  this  symptom;  thus  in  a  young  child,  whose  spine 
is  in  great  part  cartilaginous,  evidence  of  weakness  is  shown  by 
the  "loss  of  walk,"  the  refusal  to  stand,  and  by  the  instinctive 
desire  for  support,  at  an  early  stage  of  the  disease. 

(d)  Change  in  Attitude:  Awkwardness. — This  really  sums  up 
the  effects  of  the  preceding  symptoms,  since  it  is  evident  that 
pain,  weakness,  and  stiffness  must  cause  a  change  in  appearance 
and  in  the  habitual  attitudes  of  the  patient.  Such  symptomatic 
attitudes  may  be  almost  diagnostic  of  the  disease  and  of  the 
part  of  the  spine  involved. 

(e)  Change  in  the  Contour  of  the  Spine:  Deformity. — The 
deformities  of  Pott's  disease  may  be  classified  as  follows: 

1.  Bone  deformity. 

2.  Muscular  deformity. 

3.  Compensatory  deformity. 

The  characteristic  angular  projection  due  to  destruction  of 
bone  has  been  described  already. 

Muscular  deformity  is  the  distortion  due  to  muscular  spasm 
or  contraction.  Of  this,  the  wryneck,  symptomatic  of  cervical 
disease,  and  psoas  contraction  of  disease  in  the  lower  region  of 
the  spine,  are  the  most  familiar  examples. 

Compensatory  deformity  signifies  the  more  general  effect  of 
the  local  disease  and  local  distortion  upon  the  spine  as  a  whole 
(Fig.  5).    Thus  an  angular  projection  must  be  balanced  l)y  a  com- 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


29 


Fk;. 


pensatory   incurvation,    and   lateral    distortion   in    one    direction 
by  lateral   distortion  in   another. 

These  three  deformities  are,  of  course,  nearly  related,  and 
they  are  usually  combined,  although  muscular  distortion  may 
precede  the  stage  of  bone  destruction, 
while  the  compensatory  changes  are  not 
immediately  apparent.  On  the  other 
hand,  the  secondary  changes  in  the  con- 
tour of  the  spine  may  catch  the  eye  before 
the  primary  local  deformity  is  detected. 

Lateral  deviation  of  the  spine  is  not 
infrequent;  it  may  be  a  direct  distortion 
at  the  seat  of  the  disease,  caused  by  the 
destruction  of  the  side  of  a  vertebral  body 
(Fig.  22),  but  more  often  it  is  a  secondary 
effect  of  such  irregular  erosion  at  one  or 
the  other  extremity  of  the  spine,  or  the 
effect  of  muscular  contraction,  or  it  may 
be  due  to  simple  weakness,  in  which  case 
it  is  a  transient  symptom. 

Finally,  even  at  the  earliest  stage  of  the 
disease,  there  is  almost  always  a  slight 
change  in  the  outline  of  the  spine  due  to 
local  rigidity;  the  spine  no  longer  forms 
a  long,  regular  curve  when  the  body  is 
bent  forward,  but  as  one  section  remains 

,  •     •  1        I   •!        ,1  ,1  1  1  ■■' ■    direct      deforniil  \';      />', 

more  or  less  rigid  while  the  other  bends,    compensatory defor.nity.  Tiie 
the  outline  is  broken  at  or  near  the  seat    ''"^^^d  line  indicates  the  nor- 

„     ,  ,.  ,-f-,.        ^,  mal  contour  of  the  s|)ine.  % 

ot  the  disease  (rig.  / ). 

Secondary  or  Complicating  Symptoms,  (a)  Abscess.— This 
may,  by  its  size  or  situation,  cause  peculiar  symptoms.  In  the 
retropharyngeal  space  it  may  interfere  with  respiration  and 
deglutition.  In  the  thoracic  region  it  might  be  mistaken  for 
pleurisy  or  empyema,  and  when  it  forms  a  tumor  in  the  iliac 
fossa  it  may  interfere  with  locomotion. 

(b)  Paralysis  .—This  is  usually  a  late  symptom,  but  if  the 
disease  begins  in  the  centre  or  posterior  part  of  a  vertebral 
body  it  may  implicate  the  spinal  cord  before  deformity  is 
apparent. 

Abscess  and  paralysis  are  .spnptoms  that  may  be  explained 
by  Pott's  disea.se,  but  other  than  by  calling  attention  to  disease 
of  the  spine  as  a  possible  cause  of  the  complication,  they  do  not 


30 


ORTHOPEDIC  SURGEHY 


aid  one  in  determining  the  diagnosis;  for  this  reason  they  are 
chissed    as    secondary    spnptoms. 

General  Symptoms. — Especial  stress  is  laid  by  certain  writers 
upon  the  diagnostic  value  of  a  slight  but  constant  elevation  of 
the  temperature.  This  is  usually  present  if  the  disease  is  active 
or  when  an  abscess  is  approaching  the  surface,  but  the  positive 
value  of  the  s^Tuptom  in  early  or  quiescent  cases  is  doubtful. 
One  may  expect  also  that  a  patient  suffering  from  tuberculous 
disease  of  the  spine  will  present  some  evidence  of  a  painful  and 
depressing  affection,  or  some  evidence  of  inherited  or  acquired 
weakness;  yet  it  must  be  remembered  that  the  absence  of  such 
general  s}Tnptoms  would  not  exclude  Pott's  disease. 


Fig.  6 


Normal  coiitfiur  anil  flexibility  of  the  spine. 

The  Contour  and  Flexibility  of  the  Normal  Spine. — In  the 
enumeration  of  the  early  symptoms  of  Pott's  disease,  two  have 
been  noted  as  of  especial  importance — the  impairment  of  normal 
mobility  and  the  effect  of  the  disease  upon  the  contour  of  the 
spine  and  upon  the  attitudes  of  the  patient.  Therefore,  in  the 
study  of  normal  spine  the  standard  with  which  that  suspected 
of  disease  must  be  com{)ared,  mobility  and  contour,  at  different 
ages  and  iiiHlcr  different  conditions  should  receive  especial  con- 
sideration. 

The  spine  as  a  whoh;  is  a  flexible  column  presenting  certain 
constant  curves,  forward  in  the  u)>per,  backward  in  the  middle, 
and  forward  again  in  the  lowc^r  region.     These  ciu'ves  are  essen- 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


31 


tially  the  effect  of  the  force  of  gravity  and  of  the  action  of  the 
muscles  in  balancing  the  weight  of  the  body  in  the  upright  atti- 
tude. In  the  adult  they  are  practically  fixed ;  in  early  childhood 
they  can  be  nearly  obliterated  by  traction  in  the  horizontal  posi- 
tion; and  in  infancy  they  do  not  exist.  If  the  newborn  infant 
is  placed  in  a  sitting  posture  the  head  falls  forward  and  the 
spine  bends  in  one  long  backward  curve,  characteristic  of  weak- 
ness.    If  when    it   lies   on   the    back   the  legs   are   drawn  down 

Fig.  7 


Incipient  Pott's  disease.     Showing  the  break  in  tlie  C(iut<nir  of  the  spine,  of  which  the 
normal  flexibility  is  but  slightly  impaired. 


from  their  habitual  attitude  of  semiflexion,  it  Avill  be  noticed 
that  the  range  of  extension  is  somewliat  limited  because  of  the 
absence  of  the  lumbar  curve  and  the  indination  of  the  pelvis. 
When  the  gain  in  muscular  power  is  sufficient  to  enable  the  in- 
fant to  raise  and  to  control  the  head,  the  curve  of  the  neck  appears. 
Later,  when  the  child  stands,  the  erector  spinne  muscles  hold 
the  body  upright  against  the  resistance  of  the  iliopsoas  group 
and  of  the  ligaments  of  the  hip-joints;  thus  the  lumbar  curve 


32 


ORTHOPEDIC  SUROERY 


Fig.  S 


and  the  inclination  of  the  pelvis  result,  and  the  normal  contour 
of  the  spine  is  established. 

If  from  the  odontoid  process   of  the   axis  of  a  normal   indi- 
vidual in  the  erect  posture  a  line  be  dropped  to  the  ground,  this 

perpendicular  or  weight  line,  about 
which  the  weight  of  the  body  is  bal- 
anced, will  indicate  the  curves  of  the 
spine,  and  divide  it  into  sections  that 
correspond  sufficiently  well  to  function. 
The  cervical  curve  ends  at  the  second 
dorsal  vertebra,  the  thoracic  curve  at 
the  twelfth  dorsal,  and  the  lumbar  curve 
at  the  sacrovertebral  angle  (Fig.  8). 

What  has  been  spoken  of  as  the 
normal  contour  of  the  spine  varies  con- 
siderably in  the  adult.  It  is  affected  by 
the  occupation  and  by  many  other  cir- 
cumstances; of  this,  the  round  shoulders 
of  the  cobbler  or  the  weaver,  the  stoop 
of  weakness,  of  old  age,  and  the  like  are 
familiar  examples;  but  in  childhood  dis- 
tinct variations  from  the  normal  contour 
almost  always  have  a  clearly  defined 
pathological  cause.  As  the  normal  con- 
tour is  the  effect  of  the  balancing  of  the 
body  in  the  upright  posture,  it  is  evident  that  if  the  outline  of 
one  part  is  permanently  changed  compensation  for  this  change 
must  be  made  in  another  pa^rt.  Thus  when  deformity  is  well- 
marked,  the  normal  curves  of  the  spine  are  often  completely 
reversed  (Fig.  5),  and  even  at  an  early  stage  of  the  disease  the 
abnormal  contour  will  often  attract  attention,  long  before  the 
characteristic  angular  projection  has  become   apparent. 


The  divisions  of  the  spine. 


Divisions  of  the  Spine. 


Although  the  spine'is  a  flexible  cohnnn  whose  outline  changes 
with  every  moveinent  and  posture  yet  tlie  range  and  character 
of  (his  motion  vary  greatly  in  different  parts.  Jn  the  cervical 
;iti(l  lumbar  regions  the  range  is  extensive,  because  of  the  relatively 
huge  proportion  of  elastic  intervertebral  substance,  because 
of    tJK'    diif'flion    oi    the    articular    surfaces,    and  because  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


33 


centre  of    motion  is  near  the  middle  of    the  body.     Motion  is 
very  hmited  in  the  thoracic  region,  because  the  intervertebral 


Fig.  9 


^^■^^. 


XrtfU^'y"^' 


phT' 


Cross-section  of  the  body  of  a  cl>iUl  at  the  third  dorsal  vertebra.     (Dwight.) 

disks   are   thin,   because   of  the   overlapping   spinous   processes, 
and  because  it  forms  a  part  of  the  rigid  thorax,     ^^here  free 

3 


34  OB THOPEDIC  SURGERy 

motion  is  essential  to  the  habitual  attitudes,  interference  with 
normal  motion,  and  the  other  attendant  symptoms  of  disease  will 
be  apparent  earliest.  Thus  one  more  often  has  the  opportunity 
for  early  diagnosis  in  disease  of  the  lumbar  and  cervical  regions 
because  in  the  one  the  motions  necessary  in  stooping,  sitting, 
and  standing  are  constrained,  and  in  the  other  the  neck  is  stiff, 
or  the  head  is  turned  or  drawn  from  the  normal  line.  In  the 
thoracic  region  early  diagnosis  is  less  often  made,  because  in 
this  section  motion  is  so  unimportant  that  its  restraint  may 
escape  the  attention  of  the  patient  or  parent.  In  considering 
diagnosis,  therefore,  and,  in  fact,  treatment  and  prognosis,  one 
should  divide  the  spine  into  three  sections  to  correspond  with 
function : 

1.  The  neck  part,  that  allows  free  motion  of  the  head,  ending 
at  the  third  dorsal  vertebra. 

2.  The  rigid  thoracic  part,  which  includes  the  third  and  the 
tenth  dorsal  vertebrae. 

3.  The  lower  part,  made  up  of  the  two  lower  dorsal  and  the 
lumbar  vertebrae,  in  which  the  principal  movements  of  the  trunk 
are  carried  out  (Fig.  8). 

One  must  bear  in  mind  the  distribution  of  the  nerves,  because 
the  characteristic  pain  is  referred  to  their  terminations,  also, 
the  parts  in  relation  to  the  spine  at  different  levels  that  may  be 
implicated  in  the  disease.  Thus  remembering  that  the  symp- 
toms of  Pott's  disease  are  in  general,  stiffness,  weakness,  pain 
and  deformity,  one  will  always  apply  these  symptoms  to  a  par- 
ticular region  of  the  spine,  and  will  picture  to  himself  the  effect 
of  such  stiffness,  weakness,  and  deformity  at  this  or  that  vertebra; 
the  effect  of  an  abscess  in  this  or  that  situation,  and  the  area 
of  paralysis  that  might  be  caused  by  pressure  on  the  cord  at 
one  or  another  level. 

Landmarks. — The  atlas  is  on  a  line  with  the  hard  palate. 

The  axis  is  on  a  line  with  the  free  edge  of  the  upper  teeth. 

The  transverse  process  of  the  atlas  is  just  below  and  in  front 
of  the  tip  of  the  mastoid  process. 

The  hyoid  bone  is  opposite  the  fourth  cervical  vertebra. 

The  cricoid  cartilage  is  on  a  line  with  the  sixth  cervical  ver- 
tebra. 

The  upper  margin  of  the  sternum  is  opposite  the  disk  between 
the  second  and  third  dorsal  vertebrae.  The  junction  of  the  first 
and  second  sections  of  the  sternum  is  opposite  the  fourth  dorsal 
vertebra. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  35 

The^tip^of  the  ensiform  cartilage  is  opposite  the  lower  part  of 
the  body  of  the  tenth  dorsal  vertebra. 

The  anterior  extremity  of  the  first  rib  is  on  a  line  with  the 
fourth  rib  at  the  spine,  the  second  with  the  sixth,  the  fifth  with 
the   ninth,   and   the   seventh   with   the   eleventh. 

The  scapula  overlaps  the  second  and  the  seventh  ribs,  its 
lower  angle  being  opposite  the  centre  of  the  eighth  dorsal  ver- 
tebra. 

The  root  of  the  spine  of  the  scapula,  the  glenoid  cavity,  and 
the  interval  between  the  second  and  third  dorsal  spines  are  in 
the   same   plane. 

The  most  constant  landmark  from  which  to  count  is  the  spin- 
ous process  of  the  fourth  lumbar  vertebra,  which  is  on  a  line 
with  the  highest  point  of  the  crest  of  the  ilium.  The  umbilicus 
is  near  the  same  plane.  0 

The  Inclination  of  the  Pelvis. — In  the  erect  attitude  the  plane 
of  the  brim  forms  an  angle  of  50  degrees  to  60  degrees  with  the 
horizon. 

The  tip  of  the  coccyx  is  opposite  the  lower  border  of  the  sym- 
physis pubis. 

Length  of  the  Spinal  Cord. — In  the  adult  the  spinal  cord  ter- 
minates at  the  lower  margin  of  the  first  lumbar  vertebra.  At 
birth  it  extends  to  the  third  lumbar  vertebra  and  its  membranes 
to  the   second  division   of  the   sacrum. 

The  Intervertebral  Disks. — In  the  adult  the  intervertebral  disks 
form  41.9  per  cent,  of  the  cervical,  26.4  per  cent,  of  the  dorsal, 
and  44.6  per  cent,  of  the  lumbar  regions  of  the  spine  (Dwight). 

The  character  of  the  disease,  its  manifestations,  and  its  effects 
upon  the  spine  having  been  outlined,  the  student  is  now  brought, 
as  it  were,  into  actual  contact  witli  the  patient  and  his  friends. 
And  as  Pott's  disease  is  the  most  important  of  the  chronic  affec- 
tions of  childhood,  it  will  serve  as  a  type  to  illustrate  methods 
of  examination  and  of  treatment  as  applied  in  orthopedic  practice. 

The  Rational  Signs. — The  symptoms  of  Pott's  disease  vary 
decidedly,  not  only  with  the  region  of  the  spine  involved,  but 
also  with  the  age  and  suri'oundings  of  the  patient.  Like  other 
forms  of  tuberculous  disease  it  is  an  insidious  chronic  affection, 
and  its  early  symptoms  may  fail  to  attract  attention,  because 
they  are  irregular  or  intermittent.  When  the  diagnosis  is  evident, 
however,  the  mother  almost  always  remembers  that  "something  was 
wrong,"  that  the  child  was  fretful  and  disinclined  to  play,  that 
it  liked  to  lie  on  the  floor,  that  it  was  awkward  in  its  movements, 


36  OR  THOPEDIC  S  UB  GER  Y 

that  it  was  troubled  by  a  cough  or  indigestion,  or  by  oppression 
of  breathing.  One,  or  many,  of  such  symptoms  may  have  ex- 
isted for  months;  but,  as  a  rule,  it  is  not  until  deformity  appears 
that  the  child  is  brought  for  treatment.  It  is  often  after  a  fall 
or  \'iolent  play  that  the  evidence  of  pain  or  weakness  can  no 
longer  be  overlooked,  so  that  injury  is  likely  to  occupy  a  promi- 
nent place  in  the  history. 

History. — The  account  of  the  disease  given  by  the  parent  is 
usually  indefinite  and  misleading.  Certain  points,  however,  of 
relative  importance  may  be  ascertained  by  the  following  questions: 

One  asks  if  the  immediate  relatives  of  the  child  have  suffered 
from  phthisis  or  other  form  of  tuberculosis,  as  this  might  indicate 
a  predisposition  to  disease,  and  thus  affect  the  prognosis. 

One  asks  if  the  child  has  been  robust  or  the  reverse,  and  if 
recovery  from  the  ordinary  ailments  of  childhood  was  prompt 
or  tedious,  in  order  that  one  may  judge  of  the  quality  of  the 
patient. 

One  next  asks,  not  "how  long  has  the  child  been  ill?"  for  this 
is  usually  understood  to  refer  to  the  duration  of  the  more  decided 
symptoms,  but ''when  was  the  child  last  perfectly  well ?"  One 
asks  particularly  as  to  the  onset  of  the  first  symptoms  whether 
it  was  sharp  and  decided,  or  gradual  and  ill-defined;  if  the  symp- 
toms were  preceded  by  contagious  disease.  This  latter  is  an 
important  question,  because  measles,  for  example,  predisposes 
to  tuberculous  infection  or  at  least  to  its  local  outbreak,  and 
diphtheria  is  often  followed  by  paralysis  or  by  weakness  that  may 
simulate  certain  symptoms  of  Pott's  disease.  The  character 
of  the  injury  that  almost  every  patient  is  supposed  to  have  re- 
ceived is  then  investigated.  It  should  be  made  clear  whether 
the  injury  was  the  direct  cause  of  the  symptoms,  or  if  it  may 
have  simply  aggravated  or  brought  to  light  the  dormant  disease 
or  if,  as  is  often  the  case,  there  is  simply  an  indefinite  remembrance 
of  an   injury   which   has   no   connection   with   the   symptoms. 

To  establish  injury  as  the  direct  cause  of  symptoms,  the  patient 
must  have  been  well  at  the  time  of  the  accident,  the  symptoms 
must  have  followed  immediately  and  must  have  persisted  since; 
and  finally,  the  symptoms  must  be  of  a  nature  to  be  explained  by 
a  definitf!  injury. 

By  farcfiil  fjU(;stioning  one  may  usually  determine  whether  fhe 
symptoms  of  wliich  the  patient  complains  are  acute  or  chronic. 
This  is  of  irnporfjiMcc  because  tuberculosis  is  a  chronic  disease — 
one  of  the  few  chronic  diseases  of  childhood — although  its  ex- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  37 

acerbations  may  resemble  tlie  symptoms  of  acute  disease  or 
even  injury. 

However  important  a  correct  history  may  be,  it  is  upon  the 
physical    examination    that    the    diagnosis    practically    depends. 

Physical  Signs. — The  physical  examination  begins  with  in- 
spection when  one  notes  the  general  condition  and  the  actions 
and  postures  of  the  patient;  but  the  ultimate  test  is  the  com- 
parison of  the  contour  and  the  mobility  of  the  spine  susjjected 
of   disease   with    the    normal    standard. 

Voluntary  actions  and  attitudes  are  important,  because  they 
show  the  adaptation  of  the  body  to  the  disease,  the  conscious 
and  unconscious  efforts  of  the  patient  to  guard  the  weak  part 
from  strain  and  from  motions  that  caused  discomfort  and  pain. 
Direct  inspection,  palpation,  and  the  tests  of  voluntary  ana  pas- 
sive motion  are  of  still  greater  importance,  because  by  such  means 
one  may  demonstrate  thei  presence  of  disease  and  localize  it  with 
accuracy. 

The  examination  must  be  purposeful.  When  one  asks  the 
patient  to  pick  up  a  coin  from  the  floor,  it  is  to  test  the  lower 
region  of  the  spine  for  the  symptoms  of  weakness  and  stiffness. 
The  ability  to  perform  the  act  with  ease  by  no  means  excludes 
disease  of  the  spine  in  the  regions  not  especially  involved  in  the 
movements  of  stooping  or  turning  the  body,  although  this  would 
appear  to  be  the  general   belief. 

Such  tests  must  not  only  be  purposeful,  but  they  must  be 
adapted  to  the  age  and  intelligence  of  the  patient.  The  child 
that  refuses  to  pick  up  a  coin  will  often  gather  up  its  clothing, 
because  it  wishes  to  be  clothed  again.  If  it  will  not  stoop,  it 
will  rise  usually  if  placed  in  the  recumbent  or  sitting  posture — an 
equally  useful  test.  A  child  will  walk  toward  its  mother  if  placed 
at  a  distance  from  her.  It  will  always  turn  its  head  toward 
her;  thus  voluntary  motion  of  the  cervical  region  may  be  tested 
by  changing  the  mother's  position,  while  the  child  is  held  by 
the  examiner.  Young  children  that  struggle  and  resist  passive 
motion  if  placed  on  the  table,  submit  (juietly  when  held  in  the 
mother's  arms. 

Various  simple  and  efi'ective  tests  will  suggest  themselves 
to^the  examiner  who  has  a  definite  purpose  in  view,  but  much 
patience  may  be  required  in  early  cases,  and  several  examina- 
tions may  be  necessary  before  the  presence  or  absence  of  disease 
can  be  definitely  determined.  It  is  important  to  remember 
that  in  childhood  at  least,  abnormal  symptoms  always  have  a 


38  ORTHOPEDIC  SURGERY 

cause;  therefore,  a  patient  should  be  kept  under  observation  until 
the  cause  is  discovered. 

Of  all  the  early  signs  of  Pott's  disease  muscular  rigidity  or 
reflex  muscular  spasm  is  the  most  important,  since  it  precedes 
deformity  and  accompanies  it  until  cure  is  finally  established. 
It  is  a  spasm  that  resists  motion  in  all  directions;  thus  it  may 
be  distinguished  from  the  spasm  or  contraction  of  certain  groups 
of  muscles  caused  by  irritation  or  inflammation  not  connected 
with  the  spine,  for  in  such  instances  motion  is  limited  only 
in  the  directions  directly  opposed  by  the  muscular  contraction. 
True  reflex  muscular  spasm  is  quite  independent  of  the  w^ill, 
and  thus  it  may  be  distinguished  from  simple  voluntary  resist- 
ance   on    the    part    of   the    patient. 

The  muscular  rigidity  is  most  marked  in  the  neighborhood 
of  the  disease,  but  it  extends  to  a  greater  or  less  distance  accord- 
ing to  the  acuteness  of  the  local  process  and  the  susceptibility 
of  the  patient.  Even  at  an  early  stage  the  situation  of  the  dis- 
ease is  usually  shown  by  a  slight  irregularity  of  the  spine  in  the 
centre  of  the  area  made  rigid  by  muscular  spasm,  as  well  as  by 
the  change  of  contour.  This  change  in  outline  and  in  flexi- 
bility may  be  demonstrated  by  bending  the  patient  forward. 
If  the  spine  forms  a  long,  even,  regular  curve,  and  if  there  is 
no  evidence  of  pain  or  rigidity  when  such  an  attitude  is  assumed, 
Pott's  disease  is  extremely  improbable.  If,  on  the  other  hand, 
the  outline  of  the  curve  is  broken;  if  the  motion  of  one  section 
of  the  spine  is  restrained  hy  muscular  rigidity,  disease  may  be 
suspected;  and  if  other  evidence  of  tuberculous  ostitis  is  present, 
the  diagnosis  may  be  mafle  with  certainty  (Figs.  6  and  7). 

By  a  careful  physical  examination  one  may  expect  to  detect 
Pott's  disease  at  its  inception  and  to  fix  upon  its  location,  or  at 
least  upon  the  point  suspected  of  disease.  One  will  then  ask 
one's  self  if  tuberculous  disease  of  the  bodies  of  the  vertebne  of 
this  particular  region  will  satisfactorily  explain  all  the  symptoms, 
of  which  the  patient  complains;  if,  for  example,  the  pain  cor- 
responds to  the  distribution  of  the  nerves;  if  restraint  of  function 
will  explain  the  attitudes  of  the  patient,  and  if  the  change  in 
contour  is  significant  of  a  destructive  process. 

As  has  been  stated  the  symptoms  and  the  efl'ects  of  the  disease 
differ  according  to  the  function  of  the  part  of  the  spine  involved, 
and  the  further  examination  should  be  conducted,  therefore,  from 
this  .standpoint. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


39 


The  Regional  Examination. 

1.  The  Lower  Region. — Considering  the  regions  of  the  spine 
in  the  order  of  liabiHty  to  disease  one  begins  with  the  lower  sec- 
tion, comprising  the  lumbar  and  the  two  lower  dorsal  vertebrse, 
that  more  nearly  correspond  in  shape  and  function  to  the  lumbar 
than  to  the  thoracic  division. 


Fig.  10 


Fig.  11. 


Disease  of  the  upper  lumbar  region 
before  the  stage  of  deformity,  showing 
abnormal  lordosis. 


The  same  patient  (Fig.  10)  five  years  later, 
showing  deformity. 


This  is  the  region  of  constant  and  extensive  motion;  thus  the 
painful  rigidity,  characteristic  of  the  disease,  is  often  marked 
long  before  the   stage   of  bone   destruction. 

The  characteristic  attitude  of  the  patient  is  one  of  what  might 
be  called  overerectness,  and  in  many  instances  there  is  an  in- 
creased hollowness  (lordosis)  of  the  back  (Figs.  10  and  12);  thus 
the  prominent  abdomen  may  first  attract  attention.     The  walk 


40  ORTHOPEDIC  SUEQEBY 

is  careful,  and  a  peculiar  tip-toeing  step,  the  feet  being  slightly 
inverted  to  avoid  the  jar  of  striking  the  heels,  is  often  observed; 
this  is,  however,  not  a  peculiarity  of  disease  of  this  region  alone, 
but  is  rather  an  evidence  that  the  spine  is  sensitive  to  slight  jars. 
More  ^characteristic  of  lumbar  disease  is  a  peculiar  swagger 
explained  in  part  by  the  exaggerated  lordosis,  and  in  part  by  the 
loss  of  the  accommodative,  balancing  motion  of  the  lumbar  spine, 
as  the  weight  falls  alternately  on  each  limb  in  walking. 

The  increased  lumbar  lordosis,  so  characteristic  of  the  early 
s.age  of  the  disease,  is  capable  of  several  explanations.  _  It  is 
partly  voluntary,  as  bending  the  body  forward  brings  pressure 
upon  the  diseased  vertebral  body,  so  bending  it  backward  re- 
lieves this  pressure.  It  is  partly  involuntary,  caused  by  the  con- 
traction of  the  large  muscular  masses  on  the  posterior  aspect 
of  the  spine;  and  it  is  in  part  compensatory,  as  the  slight  psoas 
contraction  which  is  often  present  has  a  tendency  to  tilt  the 
pelvis  forward,  necessitating  a  greater  compensatory  backward 
inclination  of  the  body. 

As  the  disease  progresses  the  lumbar  section  becomes  straighter, 
and  finally  it  may  project  backward  in  the  characteristic  angular 
deformity.  Yet  even  after  the  lordosis  has  been  obliterated 
the  backward  inclination  of  the  body  still  continues  as  a  com- 
pensation for  the  change  in  balance,  which  the  transformation 
of  the  forward  curve  to  a  posterior  deformity  has  necessitated 
(Fig.  11).  Thus  overerectness  or  backward  inclination  of  the 
body  characterizes  the  disease  of  this  region  from  its  beginning 
to  its  end  in  uncomplicated  cases. 

Slight  psoas  contraction  as  a  part  of  the  general  muscular 
spasm  about  the  diseased  area  simply  increases  the  lordosis;  but 
if  the  contraction  is  greater,  when  for  example  an  abscess  is  pre- 
sent which  involves  the  substance  of  the  psoas  muscles  or  forms 
a  painful  tumor  in  the  pelvis,  the  erect  attitude  is  no  longer  pos- 
sible. The  thighs  are  drawn  toward  the  body,  and  the  body 
is  inclined  forward  to  relax  the  tension.  As  this  greater  con- 
traction, with  the  abscess  that  is  usually  its  cause,  is  commonly 
unilateral  the  patient  "favors"  the  flexed  limb,  and  the  resulting 
limp  is  often  mistaken  for  a  sign  of  hip  disease.  Unilateral 
psoas  contraction  is,  in  fact,  so  often  present  when  the  patient 
is  first  brought  for  treatment,  that  a  limp  and  the  accompanying 
inclination  of  the  body  m^y  be  considered  as  characteristic  of 
disease  of  the  luni}>ar  region  at  a  somewhat  advanced  stage 
(Fig.  13). 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


41 


TJie  location  of  the  jyain  depends  upon  the  distribution  of  the 
nerves  that  supply  the  diseased  vertebrae  or  that  pass  in  their 
vicinity;  it  may  radiate  over  the  inguinal  region  or  backward 
to  the  loins  or  buttocks  or  down  the  front  or  back  of  the  thighs 
to  the  knees.     Painful  "cramp'  is  sometimes  a  prominent  symp- 


FiG.   12 


Fio.    13 


.f-    Disease  of  the  lumbar  region.     First 
^  V"^.   symptom,  pain  in  the  knees. 


Disease  of  the  lumbar  region  ■with  right  iUopsoas 
ab.scess  and  psoas  contraction. 


tom;  the  limb  is  spasmodically  drawn  toward  the  body  and  the 
patient,  seizing  it  with  both  hands,  shrieks  with  pain. 

Lateral  inclination  of  the  body  is  often  present  particularly  when 
the  disease  is  at  the  lumbosacral  articulation.  It  is  usually  a  symp- 
tom of  unilateral  psoas  contraction  and  abscess;  it  may  be  due 
also  to  unilateral  contraction  of  the  muscles  of  the  back,  or  at 


42 


OB TH OPE Die  S URGER Y 


Fig.   14 


a  later  stage  it  may  indicate  collapse  or  destruction  of  one  side 
of  a  vertebral  body.  In  other  instances  it  is  not  a  fixed  attitude, 
but  is  simply  a  voluntary  adaptation  to  weakness  or  pain;  thus 
one  may  find  a  large  abscess  in  one  pelvic  fossa  unaccompanied 
by  psoa^  contraction,  while  the  body  is  inclined  toward  the  oppo- 
site side,  apparently  because  the  weight  is  supported  habitually 
on  this  limb. 

The  stiffness,  wcak?iess,  and  pain,  characteristic  of  disease  in 
this  region,  are  exemplified  in  many  ways;  for  example,  the  child 
may  be  unable  to  turn  in  bed;  it  is  slow  and  awkward  in  rising 

in  the  morning  or  in  changing 
from  an  attitude  of  rest  to  one 
of  activity.  It  often  prefers  to 
stand  rather  than  to  sit,  because 
in  the  latter  position  more  weight 
is  thrown  upon  the  sensitive  ver- 
tebral bodies.  When  seated,  par- 
ticularly when  riding  in  a  carriage 
or  street  car,  the  patient  often 
sits  upon  the  edge  of  the  seat,  the 
shoulders  only  touching  the  back, 
while  the  hands  rest  instinctively 
on  the  seat,  partially  supporting 
the  weight  and  steadying  the 
spine. 

Stooping,  a  posture  that  in- 
creases the  pressure  on  the  dis- 
eased vertebral  bodies  and  which 
necessitates  muscular  tension  and 
strain  in  regaining  the  erect  posi- 
tion, is  particularly  difficult  and 
it  is  always  avoided  by  the  patient  if  the  disease  is  at  all 
acute.  For  example,  when  the  child  is  asked  to  pick  up  an 
object  from  the  floor,  it  either  refuses  or  it  squats  on  the  heels  or 
drops  upon  the  knees  (Fig.  14)  instead  of  flexing  the  spine  as 
in  health.  Young  children,  having  seized  the  object  on  the 
floor,  regain  the  erect  attitude  by  pushing  the  body  up  by  the 
pressure  of  the  hands  on  the  thighs.  If  the  child  is  placed  upon 
the  floor  it  will,  if  possible,  seize  the  mother's  skirts  or  will  crawl 
to  a  chair  or  other  object  upon  which  the  body  may  be  drawn 
up  by  the  arms,  so  that  the  discomfort  caused  by  contraction 
of    the    back    muscles    may    be    avoided. 


Lumbar  disease.     The  manner  of  picking 
u|)  an  object. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


43 


After  the  inspection  and  the  observation  of  the  movements 
and  attitudes  of  the  patient,  the  examination  of  the  range  of 
passive  motion  is  made.     The  patient  is  placed  at  full  length, 


Fig.   15 


Showing  tlie  rigidity  of  the  spine  before  appeaiance  of  deformity. 
Fig.    16 


Test  for  pgoas  contraction. 


face  downward,  on  a  table,  and  the  range  of  extension  and  of 
lateral  motion  is  tested  by  lifting  the  legs  and  swaying  the  body 
gently  from  side  to  side   (Fig.  15).     The  spine  is  so  flexible  in 


44 


OR THOPEDIC  SURGERY 


childhooil  that  rigidity  even  in  the  upper  dorsal  region  may  be 
demonstrated  by  this  method,  and  in  testine;  the  lumbar  region 
the  thorax  should  be  fixed  by  the  hand.  While  the  patient  re- 
mains in  this  attitude,  one  should  examine  for  psoas  contraction. 
The  pelvis  is  pressed  firmly  against  the  table  with  one  hand, 
while  the  leg,  "held  in  the  line  of  the  body,  is  gently  lifted  by  the 
other  (Fig.  16).  The  normal  range  of  hyperextension  at  the 
hip-joint  should  allow  the  knee  to  be  lifted  two  or  three  inches 
from  the  table.  Restriction  of  extension  of  both  thighs,  indicat- 
ing a  slight  degree  of  psoas  contraction,  is  very  common  in  lumbar 
Pott's  disease;  but  when  the  restriction  is  marked,  and  especially 
if  it  is  unilateral,  a  deep  abscess  may  be  suspected.     Such  uni- 


FiG.   17 


A  method  of  demonstrating  psoas  contraction. 

lateral  psoas  contraction  may  be  demonstrated  by  placing  the 
child  on  the  l)ack,  allowing  the  limbs  to  hang  over  the  edge  of 
the  table,  when  the  unafi'ected  thigh  will  drop  below  its  fellow 

As  a  rule,  flexion  of  the  spine  is  much  more  restricted  in  the 
early  stage  of  the  disease  than  is  extension;  this  may  be  demon- 
strated l)y  placing  the  child  on  its  hands  and  knees,  and  lifting 
it  from  the  floor,  when  the  body,  instead  of  bending  over  the 
supporting  hands,  retains  almost  its  original  contour  (Fig.  18). 

As  has  been  stated,  even  at  an  early  .stage  of  the  disease  one 
may  detect  often  a  slight  fulness  about  the  .spinous  processes 
or  a  slight  irregularity  in  their  line,  about  wliich  the  muscular 


TUBERCULOUS  DISEASE  OF  THE  SPINE  45 

spasm  is  most  marked;  this  indicates  the  exact  seat  of  the 
disease.  Deep  pressure  on  the  spinous  processes  will  often 
cause  pain,  and  sometimes  greater  elasticity  at  this  point  may 
be  demonstrated.  Except  in  the  hands  of  an  expert,  it  is,  how- 
ever, a  test  of  comparatively  little  value;  and  again  it  may  be 
mentioned  that  local  pain  and  local  sensitiveness  to  pressure  on 
the  spinous  processes  are  not  characteristic  signs  of  Pott's  disease. 

Fig.    18 


Disease  of  the  lumbar  region  before  the  stage  of  deformity.     A  test  for  rigidity. 

Finally,  one  should  examine  for  pelvic  abscess.  This  may 
be  suspected  when  unilateral  psoas  contraction  is  present  in 
marked  degree,  although  psoas  contraction  may  be  present 
without  abscess,  and  abscess  may  be  unaccompanied  by  psoas 
contraction  when  the  substance  of  the  muscle  is  not  involved. 

The  typical  psoas  abscess,  as  pictured  and  described,  is  a 
fluctuating  tumor  that  suddenly  appears  on  the  inner  side  of 
the  thigh,  although  it  may  have  been  many  months  in  descending 
to  this  position  from  its  original  site.  Demonstrable  abscess 
is  present  at  some  time  in  at  least  50  per  cent,  of  the  cases  of 
lumbar  disease,   ami   its  detection    is    a    matter  of    importance, 


46  OB  TH  OPE  Die  SURGERY 

since  its  subsequent  behavior  will  often  materially  influence 
the  treatment.  The  child  is  placed  on  the  side,  the  thigh  is 
flexed,  and  the  hand  is  pressed  gently  down  into  the  loin  and 
iliac  fossa.  Sometimes  the  examination  will  be  made  easier 
by  extending  the  limb  and  thus  bending  the  spine  forward  to- 
ward the  hand.  Often  in  this  manner  one  can  make  out  peculiar 
sausage-like  thickening  on  one  or  the  other  side  of  the  spine,  or 
a  larger,  rounded  tumor  in  the  iliac  fossa,  the  presence  of  which 
which  would  not  otherwise  have  been  suspected. 

Diagnosis. — ^If  a  careful  physical  examination  were  made 
in  all  suspicious  cases,  by  one  at  all  familiar  with  the  ordinary 
symptoms  of  Pott's  disease,  the  field  for  differential  diagnosis 
would  be  small  indeed;  but  it  would  appear  that  such  examina- 
tions are  not  made  usually  by  the  physician  who  is  first  consulted. 
One  may  learn,  for  example,  that  the  child  has  been  circumcised 
because  of  pain  about  the  genitals,  or  because  of  weakness  of 
the  limbs,  supposed  to  be  due  to  "reflex  irritation;"  or  if  the 
patient  is  an  adult,  that  he  has  been  treated  for  sciatica,  rheu- 
matism, or  strain,  long  after  the  deformity  even,  would  have 
been    apparent    had    the    back    been    inspected. 

Pott's  disease  is  most  often  mistaken  for  some  one  of  the  fol- 
lowing affections: 

Lumbago. — ^This  may  simulate  some  of  the  symptoms  of  Pott's 
disease  of  this  region,  but  it  is  of  sudden  onset,  usually  accom- 
panied by  local  pain  and  sensitiveness  of  the  muscles  themselves. 

Strain  of  the  Back. — This  is  often  accompanied  by  stiffness 
and  pain  on  motion,  but,  like  lumbago,  its  onset  is  sudden  and 
its  cause  is  known.  The  pain  is  usually  localized  at  the  point 
of  injury;  it  is  relieved  by  rest,  and  the  restriction  of  motion  is 
in  great  degree  voluntary.  In  Pott's  disease  the  pain  is  neuralgic; 
it  is  often  worse  at  night  and  the  rigidity  is  due  to  reflex 
spasm . 

Sciatica. — The  pain  of  sciatica  is  most  often  unilateral;  it  is 
usually  confined  to  the  distribution  of  this  nerve,  which  is  often 
sensitive  to  pressure  throughout  its  course.  The  pain  of  Pott's 
disease,  if  it  is  referred  to  the  limbs,  is  usually  bilateral  and  the 
nerve  trunks  are  not  often  sensitive  to  pressure.  In  sciatica, 
movements  of  the  limbs  that  cause  tension  on  the  nerve  are  often 
painful,  while  motion  of  the  spine  is  free,  or  but  slightly  restricted, 
the  reverse  of  the  symptoms  of  Pott's  disease.  It  is  true  that 
lateral  deviation  and  even  rigidity  of  the  lumbar  spine  are  some- 
times observed  in  cases  of  lumbosciatic  neuralgia  of  long  stand- 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


47 


ing,  but  if  the  latter    symptom    is     marked  the  diagnosis  may 
be  regarded  as  open  to  question. 

Spondylolisthesis. — This  is  a  very  uncommon  affection  in  early 
life.  It  may  simulate  disease  at  the  lumbosacral  articulation.  A 
description  of  its  peculiarities  will  be  found  in  Chapter  II. 

Fig.   19 


Disease  of  the  lower  dorsal  region.     The  earliest  indication  of  deformity. 


Sacroiliac  Disease  is  far  more  likely  to  be  mistaken  for  disease 
of  the  hip-joint  than  of  the  spine;  the  pain  antl  sensitiveness 
are  usually  localized  about  the  seat  of  disease  and  the  move- 
ments ofj^the  spine   are   not   restricted. 

Lumbago,  sciatica,  and  sacro-iliac  disease  are  extremely  uncom- 
mon in  childhood,  and  if  supposed  strains  or  injuries  of  the 
back    cause    persistent    symptoms,    the    appropriate    treatment 


48  ORTHOPEDIC  SURGERY 

woiikl  be  similar  to  that  of  Pott's  disease;  that  is  to  say,  support 
of  the  suspected  part,  until  the  cause  of  the  sjonptoms  is  made 
clear. 

The  attitude  characteristic  of  Pott's  disease  of  this  region, 
the  hollow  back,  the  prominent  abdomen,  and  the  swaying  gait, 
may  be  simulated  by  hUaicral  congenital  dislocation  of  the  hip,  in 
which  the  pelvis  is  suspended  at  a  point  behind  its  normal 
position;  but  in  this  instance  the  gait  and  attitude  have  existed 
since  the  child  began  to  walk,  and  the  symptoms  of  the  disease 
are  absent.  A  similar  attitude  is  sometimes  caused  by  weakness 
or  paralysis  of  the  muscles  of  the  back,  as,  for  example,  in  the 
muscular  dystrophies.  In  such  affections  there  may  be  also  a 
disinclination  to  stoop,  and  there  may  be  limitation  of  motion, 
symptoms  that  bear  a  superficial  resemblance  to  Pott's  disease; 
but  as  there  are  no  other  signs  of  disease  of  the  spine,  it  may 
be  readily  excluded. 

When  psoas  contraction  is  present  the  resulting  limp,  often 
accompanied  by  pain  in  the  limb,  is  almost  invariably  mistaken 
for  a  s}Tnptom  of  hip  disease. 

Although  flexion  of  the  thigh  caused  by  psoas  contraction  is  a 
common  accompaniment  of*  Pott's  disease,  it  is  not  usually  an 
early  s}anptom;  thus  the  history  will  probably  call  attention 
to  symptoms  referable  to  the  spine,  that  have  preceded  it. 
Again,  the  limp  of  Pott's  disease  is  caused  simply  by  flexion  of 
the  limb. 

It  is  not  as  in  joint  disease,  accompanied  by  pain  on  functional 
use.  When,  therefore,  in  the  physical  examination  the  tension 
of  the  contracterl  iliopsoas  muscle  is  relieved  by  flexing  the  thigh 
still  further,  the  other  movements  at  the  hip,  abduction,  adduc- 
tion, rotation,  and  flexion,  are  free  and  painless.  Thus,  hip 
disease,  in  which  all  movements  are  restrained  in  equal  degree 
by  muscular  spasm,  may  be  excluded  readily,  except,  perhaps, 
in   infancy. 

Hip  Disease  in  Infancy. — At  this  susceptible  age  there  is  almost 
always  sympathetic  spasm  of  the  lumbar  muscles  in  acute 
affections  of  the  hip,  and  similar  spasm  of  the  hip  muscles  may 
be  present  in  Pott's  disease  of  the  lower  part  of  the  spine. 

Several  examinations  may  be  necessary  before  the  exact  loca- 
tion of  the  disease  can  be  determined,  and  in  doubtful  cases 
the  application  of  a  temporary  support  to  the  back  and  thigh, 
such  as  a  spica-plaster  bandage  to  relieve  the  sympathetic  spasm, 
is  a  useful  aid  in  diagnosis. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  49 

It  has  been  stated  that  extension  of  the  thigh  only  is  restrained 
by  psoas  contraction.  It  will  be  evident,  however,  that  the 
presence  of  a  large  and  painful  abscess  in  the  pelvis  or  thigh 
may  limit  motion  in  other  directions  as  well;  but  even  in  such 
cases  at  least  one  movement  is  unrestrained;  thus  disease  within 
the  joint  may  be  excluded.  ^ 

Secondary  Hip  Disease. — In  Pott's  disease  of  long  standing, 
complicated  by  abscess,  in  which  the  tissues  about  the  joiftt 
are  infiltrated  or  traversed  by  discharging  sinuses,  secondary 
infection  of  the  hip-joint  is  not  an  unusual  complication.  In 
such  cases,  when  the  limb  is  distorted  and  when  motion  at  the 
hip  is  limited  by  the  sensitive  and  contracted  tissues,  it  is  not 
easy  to  determine  the  presence  or  absence  of  joint  disease.  Doubt- 
ful cases  of  this  class  should  be  treated  symptomatica! ly. 

Pelvic  Abscess. — As  abscess  is  such  a  common  complication 
of  Pott's  disease,  it  will  be  necessary  to  consider  abscesses  of 
other  origin,  that  may  cause  occasionally  symptoms  resembling 
somewhat  those  of  disease  of  the  spine.  Such  are  the  pcrine- 
phritic  abscess,  and,  more  rarely,  that  of  appendicitis.  They  differ 
from  the  abscess  of  Pott's  disease  in  that  they  are,  as  a  rule,  acute 
in  their  onset  and  are  accompanied  by  constitutional  symptoms 
and  by  local  pain  and  tenderness.  In  such  cases  the  motions 
of  the  spine  may  be  restrained,  but  the  restraint  is  in  great  degree 
voluntary,  quite  different  from  the  rigidity  due  to  disease  of 
its  substance.  It  is  true  that  the  pelvic  abscess  of  Pott's  disease 
which  has  become  infected  may  cause  constitutional  symptoms, 
but  the  history  of  the  disability  and  discomfort  that  must  have 
preceded  the  abscess,  together  with  the  probable  presence  of 
deformity,  will  make  the  diagnosis  clear.  Chronic  abscess  in  the 
pelvis  of  other  than  spinal  origin  may  be  the  result  of  disease  of 
the  pelvic  bones,  or  of  the  sacroiliac  articulation,  or  of  the  hip- 
joint.  It  may  be  caused  by  the  breaking  down  of  lymphatic 
glands,  or  it  may  have  its  origin  in  inflammation  about  the  uterine 
appendages,  and  cases  of  so-called  idiopathic  inflammation  and 
suppuration  of  the  iliopsoas  muscle  have  been  described.  In 
childhood,  chronic  abscesses  in  this  locality  are  almost  always 
tuberculous  in  character,  and  are  caused  by  disease  of  bone,  either 
of  the  spine  or  of  the  pelvis.  Disease  of  the  spine  can  be  deter- 
mined usually  by  the  methods  already  indicated,  but  if  the  abscess 
is  of  other  origin  its  exact  cause  can  be  decided  in  many  instances 
only  by  an  operative  exploration.  Abscesses  of  this  character, 
of  slow  and   apparently  painless  formation,   may   finally   cause 


50  ORTHOPEDIC  SURGERY 

a  swelling  in  the  inguinal  region  or  about  the  saphenous  opening, 
that  in  the  adult  is  not  infrequently  mistaken  for  hernia.  In  prac- 
tically all  cases,  however,  the  tumor  of  the  abscess  may  be  made 
out  on  palpation  within  the  pelvis,  and,  although  the  contents 
of  the  external  sac  may  be  in  part  forced  back  into  the  larger 
reservoir,  its  reduction  is  very  different  in  feeling  from  that  of 
a   true   hernia. 

Peculiarities  of  Lumbar  Pott's  Disease  in  Infancy, 

Attention  has  been  called  repeatedly  to  the  great  importance 
of  careful  observation  of  the  postures  and  movements  of  the 
patient,  to  the  change  in  the  contour  of  the  spine,  and  particularly 
to  the  abnormal  lordosis  and  peculiar  attitude  of  overerectness 
in  the  early  stage  of  disease.  But  the  description  of  attitudes 
of  standing  and  walking,  and  of  the  contour  of  the  spine  which 
is  the  result  of  the  erect  posture,  does  not  apply  to  the  infant 
in  arms,  nor  can  the  spine  be  divided  into  contrasting  sections 
for  the  purpose  of  differential  diagnosis.  In  Pott's  disease  of 
infancy  the  muscular  spasm  is  usually  more  intense  and  its  extent 
is  greater;  the  child  screams  when  it  is  moved  or  when  the  diapers 
are  changed.  Slight  irregularity  of  the  spinous  processes  in- 
dicating the  position  of  the  destructive  process  is  often  evident 
and  abscess  is  not  unusual.  There  is  usually  no  difficulty  in 
determining  the  presence  of  disease  even  in  very  early  cases, 
but,  as  has  been  mentioned,  it  is  sometimes  difficult  to  decide 
whether  the  lumbar  spine  or  one  of  the  hip-joints  is  involved. 

Pott's  disease  of  infancy  jnay  be  mistaken  for  acute  rhachitis, 
or  scurvy.  The  symptoms  of  such  affections  are,  however,  not 
limited  to  the  spine,  but  involve  to  a  greater  or  less  degree  the 
limbs  and  joints,  indicating  that  the  disconrfort  and  pain  are 
due  to  a  general,   not  to  a  local  disease.  ^ 

The  Rhachitic  Spine. — The  deformity  of  the  spine,  caused  by 
rhachitis,  is  not  infrequently  mistaken  for  the  kyphosis  of  Pott's 
disease. 

It  has  been  stated  that  when  in  early  infancy  the  child  is  placed 
in  the  sitting  posture  the  spine  bends  in  a  long,  posterior  curve, 
infhV-ative  of  the  weakness  normal  at  this  age.  Such  a  curvature 
is  characteristic  also  of  acquired  weakness  and  particularly  that 
caused  by  rhachitis  in  early  childhood.  The  weak  child  that  has 
never  walked  or  that  has  "lost  its  walk"  sits  much  of  the  time  in 
its  chair,  or  is  carried  about  on  its  mother's  arms.     In  this  posture 


TUBERCULOUS  DISEASE  OF  THE  SPINE  51 

the  spine  is  habitually  bent  backward  Soon  a  slight  projection 
persists,  even  when  the  child  is  lying  down.  This  usually 
increases  in  size  and  becomes  more  resistant,  forming  a  somewhat 
rounded  and  rigid  posterior  curvature  of  the  dorsolumbar  portion 
of  the  spine. 

The  diagnosis  from  Pott's  disease  should  be  made  without 
difficulty,  because  the  evidences  of  general  rhachitis  bein§j 
present,  the  deformity  is  almost  as  much  to  be  expected  as 
would  be  distortions  of  the  legs  were  the  cliild  walking.  If 
the  patient  is  placed  in  its  habitual  sitting  posture  it  will  be  seen 
that  the  deformity  is  simply  an  exaggeration  of  a  normal  attitude. 
In  this  attitude  the  patient  remains  contentedly  for  an  indefinite 
time,  whereas  if  Pott's  disease  were  present  the  child  woukl  lie 
on  its  back  or  abdomen.  The  projection  is  rounded,  not  angu- 
lar, and  if  the  patient  ])e  placed  in  the  prone  posture  the  projec- 
tion may  be  reduced,  in  great  part,  by  raising  the  thighs  while 
gentle  pressure  is  exerted  upon  the  kyphosis.  Finally,  although 
such  extension  and  pressure  may  cause  discomfort,  there  is  com- 
plete absence  of  the  muscular  spasm  characteristic  of  Pott's  disease. 

It  may  be  stated,  then,  that  the  rhachitic  deformity  is  a  rounded 
curvature  of  the  lower  part  of  the  spine.  Its  cause  is  weakness 
and  habitual  posture.  The  rigidity  depends  upon  the  duration 
of  the  deformity.  The  pain,  if  the  rhachitis  be  acute,  is  general 
and  it  is  easily  explained  by  the  sensitive  condition  of  the 
bones  and  joints.  It  is  true  that  rhachitis  and  tuberculous  dis- 
ease of  the  spine  may  be  combined,  but  in  such  rare  instances 
the  symptoms  of  the  more  serious  local  disease  will  make  them- 
selves evident  as  distinct  from  those  of  the  general  weakness. 

Recapitulation. — The  more  characteristic  symptoms  of  disease 
of  the  dorsolumbar  region  may  be  summed   up  as  follows: 

Increased  lordosis  or  overerectness  and  a  prominent  abdomen; 
a  cautious,  constrained,  or  waddling  gait;  less  often  a  lateral 
inclination  of  the  body  or  a  limp  caused  by  psoas  contraction. 

Stiffness  of  the  spine,  which  makes  bending  or  turning  the 
body   difficult. 

Pain  referred  to  the  back,  to  the  inguinal  region,  or  to  the 
thighs,  and  in    more  advanced  cases  the  characteristic  deformity. 

Diagnosis.— The  attitude  may  be  simulated  by  congenital 
dislocation  of  the  hips  and  by  muscular  dystrophy. 

The  limp  may  be  mistaken  for  that  of  hip  disease. 

The  pain  and  stiffness  for  sciatica,  rheumatism,  lumbago, 
or   injury. 


52  OE  THOPEDIC  S  UB  GER  Y 

The  abscess  is  to  be  distinguished  from  those  from  other  sources. 

In  young  infants  tli^  s^Tiiptoms  may  be  simulated  by  hip  disease 
and  by  acute  rhachitis  or  scurvy. 

Finally,  the  deformity  of  the  subacute  form  of  rhachitis  is  to 
be   distinguished   from   that   symptomatic   of   bone   destruction. 


Disease  of  the  Thoracic  Region  of  the  Spine. 

The  normal  movement  of  this  section  of  the  spine,  which  in- 
cludes the  third  and  tenth  vertebrae,  is  as  compared  with  those 
above  and  below  it,  slight;  thus,  disease  of  this  region  may  not 
interfere  to  a  noticeable  degree  with  the  general  functions  of  the 
spine. 

As  this  part  of  the  column  curves  backward,  the  deformity, 
often  unattended  by  severe  symptoms,  is  not  infrequently  mis- 
taken for  round  shoulders  (Fig.  20).  It  seems  probable,  also, 
because  of  the  normal  backward  curve,  and  because  of  the  leverage 
exerted  by  the  weight  of  the  head  and  arms,  that  deformity  quickly 
follows  disease.  At  all  events,  patients  are  not  often  seen  before 
it  is  present,  so  that  the  diagnosis  is  usually  evident  on  inspection 
of  the   patient. 

The  attitudes  are  not  especially  significant.  If  the  lower  part 
of  the  region  is  involved,  and  if  the  disease  is  at  all  acute,  they 
are  similar  to  those  of  disease  of  the  lower  region,  viz.,  erectness, 
the  peculiar,  cautious,  in-toeing  step,  and  the  disinclination 
to    bend   the   body   forward    (Fig.    19). 

If,  on  the  other  hand,  the  upper  part  is  affected,  the  attitude 
is  often,  particularly  in  young  children,  one  of  weakness;  there 
is  a  slight  forward  inclination  of  the  body,  the  head  being  tilted 
backward  or  inclined  toward  one  side,  and  a  peculiar  shrugging, 
'squareness,  and  elevation  of  the  shoulders  is  often  noticeable 
(Fig.  21).  In  many  instances  the  apparent  elevation  of  the 
shoulders  is  in  reality  caused  by  the  deformity,  which  shortens 
the  neck  and  lowers  the  head  (Fig.  23). 

In  this  connection  it  should  be  mentioned  that  one  of  the  second- 
ary effects  of  the  disease,  the  so-called  'pigeon  chest,  may  first 
attract  the  attention  of  the  parent.  The  forward  inclination  of 
the  spine  causes  a  flattening  of  the  upper  part  of  the  chest,  while 
the  sternum  sinks  downward  and  becomes  prominent;  thus, 
the  anteroposterior  diameter  of  the  thorax  is  increased,  and  it 
is    compressed   from   side  to  side,   resembling   very    closely   the 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


53 


deformity  of  rhachitis.  As  the  pigeon  chest  of  Pott's  disease 
is  always  secondary  to  the  spinal  deformity,  its  cause,  of  course, 
becomes   apparent  on  examining  the  back. 

Of  the  early  symptoms  of  disease  of  the  thoracic  region,  pain 
and  labored  or  "grunting"  respiration  are  the  most  characteristic. 
Pain  referred  to  the  abdomen  and  to  the  front  and  sides  of  tl^ 


Fig.  20 


Fir,,  21 


Pott's  disease  of  the  middle  dorsal  region 
at  an  early  stage,  showing  slight  increase 
of  the  dorsal  Icyphosis,  without  noticeable 
change  in  the  attitude.  Contrast  with 
Fig.  21. 


Disease   of  the  upper  dorsal   region. 
Characteristic  attitude. 


chest  is  usually  an  early  and  often  a  constant  s}anptom;  thus, 
persistent  "stomach-ache"  in  a  child  should  always  lead  to  an 
examination  of  the  spine.  A  "spasm  of  pain"  is  sometimes 
excited  by  lateral  compression  of  the  chest,  as  when  the  child 
is    lifted    suddenly    by   the    parent. 


54  ORTHOPEDIC  SURGERY 

Of  much  greater  importance,  however,  is  the  labored  or  grunt- 
ing respiration,  which,  indeed,  is  almost  pathognomonic  of  Pott's 
disease.  This  "grunting"  is  caused  by  the  interference  with 
respiration,  more  particuhirly  with  the  normal  rhythmical  move- 
ments of  the  ribs.  The  restraint  is,  in  part,  due  to  muscular 
spasm  and  to  deformity  and  in  part  to  the  voluntary  effort  of  the 
patient.  The  inspiration  is  quick  and  shallow,  in  great  degree 
diaphragmatic,  and  expiration  is  accompanied  by  a  sigh  or  grunt. 
This  is  caused  apparently  by  a  momentary  closure  of  the  larynx 
to  resist  the  escape  of  air  and  thus  sudden  motion  of  the  chest 
walls.  Grunting  respiration  is,  of  course,  an  evidence  of  the 
more  acute  type  of  disease,  but  even  in  mild  cases  will  be  noticed 
when  the  patient   is   fatigued    or   during    play. 

An  aimless  cough  is  often  a  symptom  of  disease  of  the  upper 
dorsal  region,  and  spasmodic  attacks  resembling  asthma  are 
not    uncommon.  • 

In  most  instances  the  characteristic  deformity  will  appear 
on  examination,  and  in  the  exceptional  cases  in  which  it  is  absent 
a  slight  change  in  contour  will  be  apparent  when  the  trunk 
is  flexed.  In  place  of  the  long,  regular  curve  of  the  normal 
spine  a  point  where  two  distinct  outlines  unite  will  be  observed 
— one  of  which  may  be  curved,  while  the  other  is  practically 
straight    (Fig.    7). 

The  presence  of  muscular  spasm  may  be  shown  by  sudden 
movement  of  the  spine,  and  it  may  also  be  demonstrated  in 
children  by  raising  the  legs  and  swaying  the  body  from  side  to 
si  le,  as  illustrated  in  the  preceding  section  (Fig.  15).  The  change  ~ 
in  the  rhythm  of  respiration  has  been  mentioned  already.  Al- 
though the  respiratory  movement  of  the  entire  thorax  is  lessened 
in  range,  the  restraint  does  not  affect  all  the  ribs  equally;  those 
that  articulate  with  the  diseased  vertebrae  are  often  nearly  motion- 
less, while  the  movement  of  those  at  a  distance  from  the  disease 
may  apjjroach  the  normal. 

In  tracing  the  neui'algic  pain  to  its  source  the  sharp,  downward 
inclination  of  the  ribs  must  be  borne  in  mind;  thus,  the  cause 
of  pain  in  the  "stomach"  must  be  looked  for  between  the  shoulder 
})la'les. 

As  in  the  lumbar  region,  slight  lateral  deviation  of  the  spine 
is  not  unc;f)mmon,  and  it  may  be  accompanied  by  a  noticeable 
twist  or  rotation  so  that  the  ribs  on  one  side  project  sHghtly 
backward  (Fig.  22). 

In  this  region   the  sjdnal  cord  is  more  often  involved  than  in 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


55 


disease  of  other  sections;  thus,  an  awkward,  sturaljHng  gait  and 
finally  a  "loss  of  walk"  may  be  the  symptoms  that  first  attract 
attention.      The  paralysis   of  Pott's  disease   and  its   differential 


detail   elsewhere. 


diagnosis    are    considered    in    more 

Abscess  as  a  complication  of  dis- 
ease of  the  thoracic  region  cannot 
be  demonstrated  by  palpation  unless 
it  has  found  an  outlet  between  the 
ribs,  but  percussion  will  often  show 
an  area  of  dulness  or  flatness  extend- 
ing from  the  diseased  vertebrjie 
toward  the  lateral  aspect  of  the  chest. 
This  is  due  in  part,  however,  to  the 
inflammatory  thickening  of  the  tis- 
sues in  the  neighborhood.  In  rare 
instates  the  abscess  may  press 
directly  upon  the  trachea  or  bronchi 
and  cause  spasmodic  attacks  of 
dyspnoea  resembling  asthma. 

Diagnosis. — It  is  hardly  necessary 
to  mention  the  list  of  affections  that 
ma^  cause  pain  in  the  chest  or  abdo- 
men; it  is  sufficient  to  state  that 
such  symptoms  always  require  a 
physical  examination.  The  same 
statement  applies  to  irregular  respi- 
ration, to  cough,  and  to  so-called 
asthma. 

Occasionally  tuberculous   disease 
of  the   thoracic    section   in   adoles- 
cence is  practically  painless,  and  the 
resulting  deformity  is  rather  rounded 
than  angular,  so  that  it  may  be  mis- 
taken for  round  shoulders.    "Round  « 
shoulders"  is,  however,  as  a  rule,  of  long  duration.     The  exciting 
cause   or  causes  of    ])ostural    deformity,  in  occupation  or  other- 
wise, are    indicated    often   by   the   history.    The    rigidity  is  less 
marked  than  in  Pott's  disease,  and  neuralgic  pain  is  absent. 

The  contour  of  the  rhachitic  kyphosis  has  been  described. 
It  should  be  evident  that  a  more  or  less  angular  projec- 
tion in  the  upper  part  of  the  spine  could  not  be  rhachitic; 
and  yet  because  of  the   absence  of  pain  this  diagnosis  is  made 


Mari^ed  lateral  deviatiou  of  the  spine 
witTi^ntation.  Deformity  at  the  eighth 
dorsal  ■N'ertebra. 


56 


ORTHOPEDIC  S URGER Y 


not  infrequently,  and  as  a  consequence  the  activity  of  the  tuber- 
culous  disease  may  be  increased  by  massage   and  exercises. 

Lateral  deviation  of  the  spine  as  a  s}Tnptom  of  disease  hardly 
could  be  mistaken  for  the  ordinary  roiary-laicral  curvature,  in 
which    pain    and   muscular   rigidity   are   absent. 

Acute  affections  within  the  chest,  pleurisy,  'pneumonia,  and 
empyema,  are  sometimes  accompanied  by  lateral  deviation  of 
the  spine,  but  the  sudden  onset   and  the  constitutional  and  local 


Fig.  23 


Double  psoas  pontraction  of  an  extreme  degree  and  paralysis.     The  arms  used  as  supports. 

symptoms  that  accompany  such  affections  should  make  the 
cause  of  the  deformity  and  pain  evident.  It  is  because  these 
cases  are  sometimes  sent  to  orthopedic  clinics  for  braces  that 
they  seem  worthy  of  mention. 

The  abscesses  in  this  region,  as  has  been  mentioned,  cause 
usually  dulncss  or  flatness  on  percussion  of  the  chest,  and  within 
this  area  friction  sounds  and  rales  may  be  heard.  The  tuber- 
culous fluid  may  remain  indefinitely  in  the  posterior  mediastinum 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


57 


and  the  area  of  flatness  may  extend  beyond  the  axillary  line, 
yet  it  may  give  rise  to  no  symptoms.  If  the  diagnosis  of  Pott's 
disease  had  not  been  made  or  if  the  presence  of  the  abscess  had 
not  been  determined  by  the  previous  physical  examination,  it 
might  be  mistaken,  during  an  acute  exacerbation  of  the  disease 
or  constitutional  distur])ance  from  other  cause,  for  pleurisy  or 
empyema  or  even  for  phthisis.  In  all  cases,  therefore,  a  careful 
examination  of  the  chest  should  be  made  from  time  to  time  in 
order  that  the  presence  or  absence  of  abscess  may  be  recorded. 


Fig.  24 


Cervical  disease  with  abscess.     Characteristic  attitude. 


Recapitulation. — Pott's  disease  of  the  thoracic  region  is  often 
insidious  in  its  onset,  causing  no  positive  symptoms  before  the 
stage  of  deformity. 

Its  most  characteristic  symptoms  are  pain  referred  to  the  front 
and   sides    of   the   body   and   the   grunting  respiration. 

If  the  disease  is  progressive,  weakness  and  rigidity  are  present. 
The  attitude,  when  the  disease  is   in  the  lower  thoracic  region, 


58  ORTHOPED IC  S  UB GER  Y 

resembles  that  of  lumbar  disease;  if  the  upper  part  is  affected 
the  head  is  tilted  somewhat  backward  and  the  shoulders  appear 
to  be  elevated. 

In  differential  diagnosis  one  ^^•ill  consider  the  significance 
of  pain,  cough,  or  embarrassed  respiration,  and  the  affections 
for  which  abscess  or  paralysis  might  be  mistaken.  Also,  round 
shoulders,  rhachitic  deformity,  and  lateral  deviation  of  the  spine 
as   distinguished   from   the   kyphosis   of  Pott's   disease. 

2.  The  Upper  Region. — The  upper  region  of  the  spine,  which 
includes  the  cervical  and  two  of  the  dorsal  vertebrse,  corresponds 
in  freedom  of  movement  and  in  its  contour  to  the  lumbar  region. 
For  the  purpose  of  study  it  must  be  divided  into  two  parts. 
Of  these,  the  superior  or  occipitoaxoid  section  is  peculiar,  in  that 
it  contains  no  vertebral  body  or  intervertebral  cartilage,  and  in 
that  the  movements  of  the  head  are  carried  out  in  special  joints 
and  are  controlled  by  special  muscles. 

Disease  at  this  point  is  dangerous,  because  displacement  or 
fracture  of  the  weakened  vertebrae  may  cause  sudden  death 
by  pressure  on  the  vital  centres. 

Occipito-axoid  disease  is  uncommon,  and  it  is  relatively  more 
frequent   in   adult  life  than   in  childhood. 

Symptoms. — In  a  typical  case  the  symptoms  are  neuralgic 
pain  radiating  over  the  back  and  sides  of  the  head,  following 
the  distribution  of  the  auricular  and  occipital  nerves.  The 
neck  is  stiff  and  the  head  may  be  fixed  in  the  median  line,  the 
chin  being  somewhat  depressed;  but  it  is  more  often  tilted  to 
one   side,   simulating   the   attitude   of   torticollis    (Fig.    24). 

The  attitude  and  appearance  of  the  patient,  when  normal  move- 
ment of  the  neck  is  restrained  by  a  painful  disease,  is  character- 
istic; the  eyes  follow  one,  or  the  body  is  turned,  when  the  attention 
of  the  patient  is  attracted.  The  patient  moves  carefully,  in 
order  to  avoid  jar;  often  the  chin  is  instinctively  supported  by 
the  hand,  and  a  favorite  attitude  is  one  in  which  the  patient  sits 
with  elbows  on  the  table,  the  hands  supporting  the  liead  (Fig.  25). 
If  the  attempt  is  made  to  raise  the  cliin,  or  to  rotate  the  head,  the 
patient  seizes  the  hands  of  the  examiner,  and,  it  may  be,  screams 
in  upj^rehension.  There  may  be  slight  huhfing  and,  thickening 
of  the  tissues  at  the  seat  of  disease.  The  affected  vertebrae  are 
usually  sensitive  to  direct  pressure,  and  not  infrequently  deep 
fluctuation  in  the  suboccipital  triangle  can  be  made  out. 

The  athmxoid  junction  lies  just  behind  the  posterior  wall 
of  the  pharynx,  on  a  line  with  the  upper  teeth.     Here  cfhsces,^ 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


59 


often  presents  itself,  occasionally  early  in  the  course  of  the  disease, 
causing  symptoms  of  obstruction,  such  as  snoring,  change  in 
the  quality  of  the  voice,  difficulty  in  swallowing,  or  spasmodic 
attacks  of  so-called  croup.  When  abscess  is  present  and  when 
the  disease  is  at  all  acute,  the  reclining  posture  sometimes 
aggravates  the  symptoms,  so  that  "getting  the  child  to  bed" 
is  often  a  tedious  and  difficult  task. 


Fig.  25 


Cervical  disease.     A  characteristic  attitude. 

In  certain  cases  one  can  determine  whether  the  disease  is  of 
the  occipitoatloid  or  of  the  adoaxoid  articulation,  but,  as  both 
joints  are  to  a  great  extent  controlled  by  the  same  muscles,  this 
is  often  impossible. 

The  uppermost  joint,  that  between  the  atlas  and  occiput, 
permits  the  nodding  movement  of  the  head,  or  flexion  and  ex- 
tension on  the  spine;  while  the  adoaxoid  joint  permits  rotation 
of  the  atlas  about  the  axis  to  the  extent  of  about  30  deirrees  in 
either  direction. 

If  the  disease  be  in  the  upper  joint  the  nodding  movements 


60 


ORTHOPEDIC  SURGERY 


w-ill  be  more  restricted  than  those  of  rotation,  and  vice  versa. 
The  motion  of  the  cervical  region  is  very  free;  so  that  to  make 
the  test  one  must  grasp  the  neck  firmly  in  order  to  restrain  motion 
except  in  the  joint  under  examination.  Because  of  this  freedom 
of  movement,  restriction  of  motion  of  the  upper  articulations 
is  often  overlooked  when  the  disease  is  of  the  subacute  variety. 
The  Lower  Cervical  Region.— The  s}Tnptoms  of  disease  of  the 
lower  cervical  section,  although  similar  in  character,  are  often 
less  marked  than  those  of  the  upper  region.  The  cervical  spine 
becomes  straighter,  and  often  a  slight  backward  projection  or 
thickening  indicates  the  position  of  the  disease.  The  head  is 
usually  turned  to  one  side  by  contraction  of  the  lateral  muscles  in 


Fio.   26 


Disease  of  the  middle  cervical  region  at  an  early  stage. 

an  attitude  of  wryneck  (Fig.  26).  The  pain  is  referred  to  the 
neck,  to  the  sternal  region,  or  down  the  arms,  following  the  dis- 
tribution of  the  brachial  plexus. 

In  the  more  advanced  cases  one's  attention  may  be  attracted 
to  the  cervical  region,  because  the  neck  seems  short  and  because 
the  head  is  tilted  liackward.  The  entire  back  shows  a  com- 
pensatory flattening,  yet  no  deformity  is  apparent  until  the  occiput 
is  raised  and  drawn  forward,  when  a  shelf-like  projection  may 
be  felt  at  what  appears  to  be  the  extremity  of  the  spine,  but  which 
Is  really  an  angular  deformity  at  the  third  or  fourth  vertebra. 

This  emphasizes  the  importance  of  a  careful  observation 
of    the   contour    of   the  spine,  and  the  necessity  of    explaining 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


61 


to  one's  self  every  change  from  the  normal  that  may  be 
noticed. 

Disease  at  the  cervicodorsal  junction  resembles  in  its  symptoms 
that  of  the  upper  dorsal  region.  The  head  is  usually  tilted  back- 
ward (Fig.  21)  or  it  may  be  turned  to  one  side.  Disease  at  this 
point  is  often  subacute  in  character,  and  paralysis  from  implica- 
tion of  the  spinal  cord  sometimes  appears  before  deformity  is 
apparent.     Occasionally  irregularity  of  the  pupils  is  present. 

The  spinous  process  of  the  seventh  cervical  or  first  dorsal 
vertebra  is  often  prominent  (vertebra  prominens)  in  normal 
individuals,  and  it  may  be  mistaken  for  the  deformity  of  disease, 
especially  when  pain  about  this  point  is  a  symptom,  as  in  hys- 


Fio.  27 


Deformity  at  the  cervical  vertebra  indicated  by  the  wrinkle  ia  the  neck.     The  attitude  of 
the  head  and  the  compensatory  projection  in  the  lumbar  region  are  characteristic. 

terical  or  hypertesthetic  persons.  If  such  projection  is  symp- 
tomatic of  disease  there  is  almost  always  a  slight  compensatory 
flattening  of  the  spine  below  the  point  and  a  certain  degree  of 
rigidity  of  the  surrounding  muscles. 

Diagnosis. — As  stiffness  and  distortion  of  the  neck  are  the 
most  prominent  symptoms  of  disease  of  this  region,  one  must 
consider  first  the  forms  of  torticollis  for  which  it  might  be  mis- 
taken.    In  typical  torticollis  the  distortion  of  the  head  is  caused 


62  ORTHOPEDIC  SURGERY 

almost  invariably  by  contraction  of  the  muscles  supplied  by 
the  spinal  accessory  nerve,  the  sternomastoid,  and  trapezius, 
thus,  the  chin  is  slightly  elevated  and  turned  away  from  the 
contracted  muscle. 

Congenital  forticoUis,  which  has  existed  from  birth,  is  not  ac- 
companied by  pain  and  it  could  hardly  be  mistaken  for  a  symp- 
tom of  disease. 

Acute  rheumatic  torticollis,  "stiff  neck,"  is  sufficiently  common 
to  be  familiar  in  its  characteristics.  It  is  of  sudden  onset,  "  in  a 
single  night;"  the  affected  muscles  are  sensitive  to  pressure;  the 
course  of  the  affection  is  short  and  it  is  of  comparative  insignificance. 

A  more  persistent  form  of  acute  torticollis,  characterized  by 
muscular  spasm  and  by  local  sensitiveness,  sometimes  accompanies 
enlarged  or  suppurating  cervical  glands;  it  may  follow  "ear-ache," 
"tonsillitis,"  "sore-throat,"  or  any  form  of  irritation  about  the 
pharynx.  This  form  of  wryneck  is  not  only  very  painful,  but 
it  may  persist  indefinitely,  and  permanent  deformity  may  result. 
The  onset  is  usually  sudden;  the  pain  and  sensitiveness  are  local 
and  are  confined,  as  a  rule,  to  the  contracted  part.  The  sterno- 
mastoid and  trapezius  muscles  are  most  often  involved;  thus, 
the  wryneck  is  typical.  If  the  tension  be  relaxed  by  inclining 
the  head  toward  the  contracted  muscles,  motion  of  the  spine 
itself  will  be  found  to  be  free  and  painless;  but  if  traction  is 
made  on  the  contracted  muscles  it  causes  discomfort,  and  it 
is  usually  resisted  by  the  patient. 

In  disease  of  the  occipitoaxoid  region  the  distortion  of  the 
head  is  by  no  means  typical  of  sternomastoid  contraction;  it 
may  be  tilted  up  or  down  or  laterally  to  an  exaggerated  degree. 
In  other  words,  the  wryneck  of  Pott's  disease  is  an  irregular  dis- 
tortion, because  it  is  not  dependent  on  the  contraction  of  a  par- 
ticular muscle  or  muscular  group.  "In  torticollis  the  chin  is 
turned  away  from  the  contracted  muscle,  while  in  Pott's  disease 
it  is  turned  toward  the  contracted  muscle."  This  is  an  axio- 
matic expression  of  the  fact  that  the  distortion  of  the  head  symp- 
tomatic of  atloaxoid  disease  depends,  in  great  degree,  upon 
the  spasm  of  the  small  muscles  that  directly  control  these  joints, 
the  recti  and  obliqui  not  upon  the  contraction  of  the  mastoid 
muscle,  as  in  the  ordinary  form  of  wryneck.  Again,  the  con- 
traction, symptomatic  of  Pott's  disease,  of  this  or  other  regions, 
is  the  result  of  muscular  spasm  that  checks  painful  motion. 
If  the  head  be  grasped  firmly  by  the  hands  and  if  gentle  trac- 
tion   is  m;ule,  the  distortion  may  often  l>e  overcome  without  (lis- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  63 

comfort  to  the  patient.  If  similar  traction  is  made  upon  the 
contracted  muscles  of  acute  wryneck  the  pain  is  increased  and 
the  patient  protests. 

In  disease  of  the  middle  cervical  region,  however,  the  distor- 
tion may  resemble  closely  that  of  acute  torticollis;  for  if  the 
latter  is  caused  by  the  irritation  of  inflamed  or  suppurating 
glands  there  is  often  sensitiveness  to  manipulation,  with  more  or 
less  general  muscular  spasm.  In  such  cases  the  diagnosis  may 
be  impossible  until  apparatus  has  been  applied  to  rest  the  part 
and  to  correct  the  deformity. 

As  has  been  stated,  the  head  may  be  tiltetl  backwiird  to  com- 
pensate for  deformity  in  the  middle  cervical  region,  and  in  some 
instances  it  may  be  drawn  backward  by  spasm  of  the  posterior 
muscles.  vSuch  a  case  might  be  mistaken  for  cervical  opisiJwtonos, 
or  posterior  torticollis,  which  is  sometimes  seen  in  young  infants 
suffering  from  exhausting  diseases,  basilar  meningitis,  and  the 
like.  In  such  conditions,  however,  the  characteristic  symptoms 
of  Pott's  disease  are,  of  course,  absent. 

The  opposite  attitude,  viz.,  a  forward  droop  of  the  head  due  to 
weakness  of  the  trapezii  muscles,  is  not  uncommon  as  a  sequence 
of  diphtheria  or  other  forms  of  contagious  disease.  This  droop 
may  be  accompanied,  also,  by  contraction  of  one  of  the  sterno- 
mastoid  muscles  and  by  pain.  In  such  cases  the  history  of 
the  preceding  affection,  the  weakness  or  paralysis  of  other  parts, 
as  of  the  soft  palate,  of  accommodation  of  the  eyes  and  the  like, 
together  with  the  general  bodily  weakness  should  make  the 
diagnosis  clear. 

Injury  of  the  upper  segment  of  the  spine,  strain,  contusion, 
or  fracture,  unless  efficiently  treated,  may  cause  symptoms  re- 
sembling very  closely  those  of  tuberculous  disease;  for  example, 
pain,  radiating  over  the  back  of  the  heafl,  rigidity  and  deformity 
of  the  neck,  and  even  infiltration  and  local  tenderness  about 
the  injured  part.  Such  cases,  when  seen  several  weeks  or  months 
after  the  accident,  are  puzzling,  because  one  may  be  in  doubt 
whether  the  symptoms  were  caused  by  a  simple  injury  or  whether 
tuberculous  infection  may  have  followed  or  preceded  it.  In 
such  cases  a  positive  diagnosis  cannot  be  made  imtil  the  effect 
of  rest  and  protection  has  been  observed — that  is  to  say,  suspi- 
cious cases  should  be  treated  as  one  would  treat  actual  disease. 
If  the  case  is  simply  one  of  injury  recovery  will  be  rapid  and 
complete,  while  if  disease  is  present  the  symptoms  only  will 
be  relieved. 


g4  ORTHOPEDIC  SURGERY 

The  occipitoaxoid  articulations  may  be  involved  in  acute  ar- 
ticular rheumatism,  in  rheumatoid  arthritis  and  the  like.  If  the 
manifestations  are  general  in  character  the  diagnosis  is,  of  course, 
easily  made;  but  occasionally  the  joints  at  the  upper  extremity 
of  the  spine  may  be  involved  in  what  is  apparently  a  local 
infectious  arthritis,  in  which  the  s}niiptoms  are  of  sudden  onset 
it  mav  be  accompanied  by  fever  and  constitutional  disturbance. 
The  sudden  onset  and  rapid  recovery  if  proper  treatment  is 
applied  are  the  diagnostic  points. 

^ibscess  in  the  cervical  region  is  a  secondary  spiiptom,  and  al- 
though the  change  in  the  voice  or  the  difficulty  in  breathing  or 
swallowing  may  be  the  most  noticeable  symptoms,  yet  they  are 
always  accompanied  by  some  of  the  characteristic  signs  of  Pott's 
disease.  Whenever  the  diagnosis  of  cervical  disease  is  made  one 
should  examine  the  throat,  and  whenever  a  chronic  retropharyngeal 
abscess  is  present  one  should  look  for  the  symptoms  of  Pott's 
disease.  The  diagnosis  of  the  retropharyngeal  abscess  can  be 
made  only  by  inspection  and  palpation;  therefore,  one  need  only 
mention  the  fact  that  symptoms  of  obstruction  in  the  throat, 
similar  to  those  of  abscess,  may  be  caused  by  adenoid  growths 
and  by  enlarged  tonsils. 

Retropharyngeal  abscess  is  by  no  means  always  symptomatic 
of  Pott's  disease.  It  may  be  one  of  the  sequels  of  contagious 
disease  or  a  complication  of  pharyngitis.  It  is  then  rapid  in  its 
onset  and  is  not  accompanied  by  the  symptoms  of  Pott's  disease. 

Recapitulation. — If  the  disease  is  of  the  upper  or  occipito- 
axoid region  the  head  is  usually  fixed  in  an  attitude  of  deformity, 
which  may  be  slight  or  extreme.  If  the  disease  is  of  the  middle 
region,  the  attitude  more  often  resembles  that  of  ordinary  torti- 
collis. In  the  lower  region  marked  spasm  of  muscles  is  unusual, 
but  the  head  inclines  backward  or  toward  one  shoulder. 

The  contour  of  the  cervical  spine  changes  as  the  disease  pro- 
gresses; the  nonnal  anterior  curvature  is  obliterated;  thus,  the 
head  is  pushed  forward,  while  the  dorsal  section  of  the  spine 
becomes  flat  or  even  incurvated  in  compensation.  The  seat 
of  tlie  disease  is  often  shown  by  an  area  of  thickening  or  local 
sensitiveness  to  deep  pressure. 

Disease  of  the  joints  of  the  upper  or  occipitoaxoid  section  is 
often  acute  in  onset,  in  some  instances  apparently  a  form  of 
synovial  tuberculosis,  and  al)scess  is  a  very  fretjuent  complica- 
tion. Differential  diagnosis  of  disease  in  this  region  will  include 
the  consideration  of  the  various  forms  of  wryneck,  cervical  opis- 


TUBERCULOUS  DISEASE  OF  THE  SPINE  65 

thotonos,  diphtheritic  paralysis,  and  injury.  Secondary  abscess 
must  be  distinguished  from  simple  retropharyngeal  abscess  and 
from  other  forms  of  obstruction  in  the  throat. 

Diagnosis  in  General. — Weakness  and  the  so-called  "loss 
of  walk"  are  well-known  symptoms  of  Pott's  disease,  and  on 
this  account  children  suffering  from  different  forms  of  weakness 
or  paralysis  are  often  sent  to  orthopedic  clinics  for  the  treatment 
of    "spine   disease." 

Certain  forms  of  paralysis  bear  a  superficial  resemblance  to 
some  of  the  symptoms  of  Pott's  disease;  for  example,  pseudo- 
hypertrophic muscular  dystrophy  to  the  attitude  caused  by  disease 
of  the  lumbar  region,  and  diphtheritic  paralysis  to  that  of  the 
dorsal  region.  Spastic  paralysis,  of  cerebral  origin,  resembles 
somewhat  the  paralysis  of  Pott's  disease,  but  it  may  be  differen- 
tiated by  the  absence  of  pain  by  the  history,  and  by  what  is 
apparent   in  most   cases,   the  mental   impairment. 

Primary  spastic  spinal  paraplegia  resembles  the  paralysis  of 
Pott's  disease  more  closely,  but  here,  again,  the  essential  symp- 
toms of  a  destructive  disease  of  the  spine  are  absent.  The 
contractions  combined  with  the  weakness  and  pain  that  some- 
times follow  cerebrospinal  meningitis  may  be  mistaken  for  the 
symptoms  of  bone  disease,  but  they  are,  as  a  rule,  readily  ex- 
plained by  the  history  of  the  case. 

Forms  of  organic  disease  of  the  spine  other  than  tuberculosis 
as,  for  example,  malignant  disease,  syphilis,  spondylitis  defor- 
mans and  the  like  in  which  the  question  in  differential  diagnosis 
is  not  of  the  presence  or  absence  of  disease  but  rather  of  its 
nature  are  described   in   Chapter  II. 

The  list  of  affections  that  has  been  considered  in  the  differ- 
ential diagnosis  is  a  long  one,  but  it  has  been  made  up  from 
actual  experience.  Most  of  the  mistakes  in  diagnosis  can  be 
explained  by  carelessness  or  ignorance,  or  because  of  insufficient 
opportunity  for  examination;  but  in  the  earliest  stages  of  the 
disease  repeated  examinations  and  even  tentative  treatment  may 
be  necessary  before  the  diagnosis  is  confirmed. 

The  Roentgen  Ray  Photography  as  a  Means  of  Diagnosis. — Roentgen 
pictures  are  of  comparatively  little  importance  from  the  diag- 
nostic standpoint,  but  they  may  be  of  value  as  a  means  of  deter- 
mining the  exact  extent  of  the  disease.  If  the  negative  is  well- 
defined,  the  diseased  vertebrte  are  seen  to  be  irregular  in  outline, 
or  they  may  be  lost  in  a  peculiar  blur.  By  counting  from  above 
and  below  the  boundaries  of  the  disease  may  be  made  out,  but 

5 


66 


OR TBOPEDIC  S UR GER Y 


inferences  as  to  its  character  and  quality  must  be  made  from 
the  rational  and  physical  signs  (Fig.  35).  The  tuberculin  test 
is  considered  in  Chapter  V. 

The  Record  of  the  Case.— The  history  and  the  results  of  the 
examination  of  the  patient  should  be  recorded  somewhat  in  the 
following  order: 

1.  The  family  and  the  personal  history. 

2.  The  history  of  the  disease,  with  especial  reference  to  its 
mode  of  onset,  its  probable  duration,  to  the  noticeable  symptoms, 
and  to  previous  treatment. 

3.  The  physical  examination.  This  should  include  the  gen- 
eral condition  of  the  patient,  the  height  and  weight,  the  attitude, 
the  character  of  the  disease,  whether  progressive,  as  indicated 
by  muscular  spasm  and  pain  on  motion,  or  quiescent,  the  pres- 
ence of  abscess  or  paralysis  as  a  complication,  and,  finally,  the 
position  and   extent  of  the  disease.     This  is  best  shown  by  a 

Fig.  28 


Tracings  of  the  spine  illustrating  recession  of  deformity  under  treatment. 

tracing,  made  by  means  of  a  strip  of  lead  or  pure  tin,  of  such 
thickness  that  it  may  be  readily  moulded  on  the  spine  and  yet 
hold  its  shape  when  removed  (Fig.  28). 

The  tracing  should  be  of  the  entire  spine,  made  while  the 
patient  lies  extended  in  the  prone  position,  and  the  exact  location 
of  the  most  prominent  spinous  process  should  l)e  marked  upon 
it.  In  determining  the  position  of  the  disease  it  is  well  to  count 
the  spinous  processes  from  below  upward,  beginning  with  that 
of  the  fourth  lumbar  vertebra,  which  lies  on  a  line  drawn  between 
the  highest  points  of  the  iliac  crests.  Tbere  are  other  landmarks 
that  are  approximately  correct.  Sometimes  the  last  rib  may  be 
trace<l  to  its  origin;  the  scapula  covers  the  second  and  seventh 
ribs,  the  root  of  the  spine  of  the  scapula,  and  the  middle  point 
of  the  glenoid  cavity  being  on  a  line  with  the  tliird,  and  its  in- 
ferior angle  opposite  the  tip  of  tlie  s(!vcnth  dorsal  spinous  process. 
The  upper  margin  of  the  sternuiri  is  opposite  the  interval  })etween 


TUBERCULOUS  DISEASE  OF  TEE  SPINE  67 

the  second  and  third  dorsal  vertebrae.  In  many  instances  the 
vertebra  prominens  and  the  spinous  process  of  the  axis  can  be 
identified.  Such  landmarks  are,  of  course,  somewhat  displaced  if 
the  deformity  is  extreme,  but  they  are  always  sufficiently  correct 
to  check  errors  in  counting  the  spinous  processes. 

The  history  furnishes  a  foundation  on  which  treatment  is 
conducted  and  from  which  its  results  may  be  determined.  The 
study  of  final  results  has  become  of  great  importance  in  ortho- 
pedic surgery,  and  on  this  account  the  record  should  present 
the  condition  of  the  patient  when  treatment  is  begun,  in  a  form 
that  may  be  readily  understood,  not  only  by  its  writer  when 
details  have  been  forgotten,  but  by  anyone  who  may  in  after 
years  consult  it.  In  this  history  the  complications  and  incidents 
and  the  changes  in  the  treatment  should  be  noted  at  regular 
intervals  while  the  patient  is  under  observation. 

Treatment. — The  general  treatment  of  tuberculous  disease  is 
considered  in  Chapter  V.  Pott's  disease  is  the  most  important 
of  the  tuberculous  afl'ections  of  the  bones,  and  the  importance  of 
proper  surroundings,  proper  food,  sunlight,  and,  above  all,  open 
air  both  day  and  night,  if  possible,  can  hardly  be  exaggerated. 

The  General  Principles  of  Mechanical  Treatment, — Under  normal 
conditions  the  weight  of  the  head  and  of  the  thoracic  and  abdom- 
inal organs  tends  to  bend  the  spine  forward  and  downward — a 
tendency  that  is  resisted  by  the  action  of  the  muscles  of  the  back. 
If  the  resistance  is  weakened,  as  in  Pott's  disease  by  the  direct 
destruction  of  the  weight-bearing  portion  of  the  spine,  this  ten- 
dency toward  deformity  is,  of  course,  greatly  increased.  Thus, 
the  pressure  of  the  superincumbent  weight  upon  the  weakened 
part  and  the  strain  of  motion  are,  from  the  mechanical  stand- 
point the  most  important  factors  in  the  production  of  deformity. 

When  the  body  is  bent  forward,  as  in  the  stooping  posture, 
the  intervertebral  disks  are  compressed  and  the  pressure  upon 
the  vertebral  bodies  is  increased.  When  the  body  is  held  erect 
or  is  bent  backward  this  pressure  is  lessened,  and  a  part  of  the 
weight  is  transferred  to  the  articular  processes  and  to  the  poste- 
rior parts  of  the  column.  The  object  of  a  brace  or  other  support 
is  to  hold  the  spine  in  the  extended  position,  so  that  pressure 
on  the  diseased  vertebrte  may  be  removed.  One  aims  to  splint 
the  spine  as  effectively  as  if  it  were  broken,  in  order  to  relieve 
the  discomfort  and  pain,  so  depressing  to  the  patient,  and  to 
secure  the  rest  that  is  essential  to  repair. 

The  effectiveness  of  a  particular  splint  or  support,   whether 


68  OB THOPEDIC  S UR GEB Y 

applied  to  a  broken  bone  or  to  a  diseased  spine,  depends  upon 
the  area  that  it  covers  on  either  side  of  the  part  to  be  supported 
and  upon  the  accuracy  of  its  adjustment,  as  well  as  upon  the 
damage  that  the  part  has  already  sustained,  and  the  strain  to 
which  it  still  may  be  subjected. 

From  this  standpoint  it  is  evident  that  it  is  difficult  to  apply 
effective  support  to  the  trunk  because  of  its  size,  shape,  and  con- 
tents, and  it  is  apparent  also  that  the  mechanical  conditions 
are  more  favorable  in  some  parts  than  in  others.  For  example, 
the  splint  is  likely  to  be  effective  when  the  disease  is  of  the  lower 
dorsal  region,  because  its  two  extremities,  attached  to  the  pelvis 
and  to  the  shoulders,  are  equidistant  from  the  point  to  be  sup- 
ported. These  conditions  are  reversed  in  disease  of  the  upper 
thoracic  region,  because  the  weight  of  the  head  and  of  the  arms 
tends  to  increase  the  deformity,  and  because  of  the  insufficient 
leverage  that  can  be  secured  for  the  supporting  appliance.  The 
pelvis  is  the  base  of  support  for  all  forms  of  splints,  and  if  it  is 
smaller  than  the  abdomen,  as  in  infancy,  the  adjustment  of  effi- 
cient support  is  more  difficult  than  in  older  subjects. 

In  actual  practice  the  treatment  of  Pott's  disease  is  influenced 
by  the  age  of  the  patient,  the  situation  of  the  disease,  the  dura- 
tion of  the  deformity,  and  by  many  other  circumstances,  but 
the  relative  efficiency  of  braces  or  other  appliances  may  be  de- 
cided on  purely  mechanical  grounds.  Thus,  as  the  ultimate 
deformity  of  Pott's  disease  is,  in  great  degree,  caused  by  the 
Jorce  of  gravity  acting  on  a  weakened  spine,  the  most  effective 
treatment  must  be  fixation  in  the  horizontal  position,  for  in  this 
position  the  strain  of  use  and  the  pressure  of  superincumbent 
weight  can  be  removed  completely. 

Horizontal  Fixation. — Apparatus  for  this  treatment  must  be  quite 
independent  of  the  bed  on  which  it  may  be  placed,  and  of  such 
appliances  several  forms  may  be  employed. 

The  reclinationgypsbettes  of  Lorenz^  is  simply  a  posterior  case 
of  plaster-of-Paris  enclosing  the  head  and  body. 

The  Phelps  bed  is  somewhat  similar.  A  thin  board  is  cut  in 
the  outline  of  the  child's  body  and  extended  legs.  It  is  padded 
with  wadding  and  covered  with  cotton  cloth;  the  patient  is  then 
placed  upon  it,  and  plaster  bandages  are  applied  to  enclose  the 
body  and  the  legs.  The  front  is  then  cut  away,  so  that  the  patient 
may  l^e  removed  from  the  bed  for  an  occasional  bath  and  change 
of  clothing.^ 

'  HofTa,  Lehrbuch  der  Orthopiidischea  Chir.,  3d.,  p.  324. 

*  The  Phelps  Plaster-of-Paris  Bed,  Trans.  Amer.  Ortho.  Assoc,  1891,  vol.  iv.  p.  83, 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


69 


The  wire  cuirasse  has  been  popularized  by  Sayre;*  it  is  an  effec- 
tive appliance,  although  somewhat  cumbersome  and  expensive. 

An  effective  and  convenient  form  of  support  is  the  Bradford 
frame  or  stretcher.  This  is  a  rectangular  frame  a  few  inches 
longer  and  slightly  wider  than  the  patient's  body.  Over  the 
frame  covers  of  strong  canvas  are  drawn  tightly  by  means  of  cor- 

FiG.   29 


Brailford's  bed-frame.      (Bradford  and  Lovett.) 

set  lacings  or  straps  on  its  under  surface,  leaving  an  interval 
beneath  the  buttocks  for  the  use  of  the  bed-pan  (Fig.  29). 

The  efficiency  of  this  appliance  may  be  increased  by  changing 
it  in  several  particulars,  and  the  following  description  applies  to 
the  apparatus  used  by  the  writer: 

The  stretcher  frame  is  made  of  ordinary  galvanized  gas-pipe 
or  steel  tubing;  of  a  smaller  diameter.     It  should  be  about  four 


Fk;.  30 


The  modified  frame  with  the  bandage. 


inches  longer  than  the  child  and  about  four-fifths  as  witle,  the 
lateral  bars  corresponding  to  the  articulating  surfaces  of  the  four 
extremities  with  the  trunk.  The  ordinary  dimensions  are  seven 
and  one-half  by  thirty-eight  inches,  or  the  width  to  length  about 
as  one  to  five. 

At  first  thought  it  would  seem  that  the  side  bars  might  cause 
uncomfortable   pressure   on   the   overhanging   shoulders,    but   as 

1  R^dard,  La  gouttiere  de  Bonnet,  Chir.  Orthopedique,  p.  243.  . 


ORTHOPEDIC  SURGERY 


the  arms  are  set  upon  the  middle  of  the  lateral  aspect  of  the  trunk 
and  thus  on  a  considerably  higher  plane  than  the  dorsum,  there 
is  but  bare  contact  when  the  cover  is  fairly  rigid.     Before  apply- 


FiG.  31 


t7 


L 


ijl^qa^ia^:^^^^^'^^^^^^^^^^ 


I 


Tbe  stretcher  frame,  showing  the  canvas  cover  and  apron. 


Fig.    32 


The  frame  bent  to  assure  overextension  of  the  spine.     The  recession  of  deformity  obtained 
in  this  case  is  shown  by  the  tracings,  Fig.  28. 


Fig.   33 


The  modified  stretcher  frame  .showing  overextension  of  the  spine,  with  traction  for  the 
hea<l  and  Umbs  a.s  applied  for  Pott's  paraplegia.  Caused  by  disease  in  the  upper  dorsal 
region.     (See  Fig.  56.) 

ing  the  cover  one  may  with  advantage  wind  bandages  tightly 
about  the  frame  at  the  point  which  is  to  support  the  trunk  in 
order  to  make  the  support  as  unyielding  as  possible  (Fig.  30). 
The  cover  should  be  of  strong  canvas  suitably  protected  in  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE  71 

centre  by  rubber  cloth.  This  is  apphed  and  is  drawn  tight  by 
means  of  corset  lacings  antl  straps.  Upon  this  two  thick  pads 
of  felt  are  sewed;  these  should  be  about  seven  inches  in  length 
and  about  three-quarters  of  an  inch  in  thickness,  so  placed  as 
to  pass  on  either  side  of  the  spinous  processes  at  the  seat  of  the 
disease,  thus  protecting  them  from  pressure,  fixing  the  part  more 
firmly,  and  increasing  the  leverage  of  the  apparatus.  The  child, 
wearing  only  an  undershirt,  stockings,  and  diaper,  is  placed 
upon  the  frame  and  is  fixed  there  usually  by  a  front  piece  or  apron 
similar  to  that  used  with  the  spinal  brace.  As  soon  as  the  patient 
has  become  accustomed  to  the  restraint  one  begins  to  over- 
extend  the  spine  by  bending  the  bars  from  time  to  time  upward 
beneath  the  kyphosis  with  the  aim,  as  has  been  stated,  of  actually 
separating  the  diseased  vertebral  bodies  and  obliterating  all  the 
physiological  curves  of  the  spine,  so  that  the  body  shall  be  finallv 
bent  backward  to  form  the  segment  of  a  circle.  The  greatest 
convexity  is  at  the  seat  of  the  disease,  and  as  the  head  and  lower 
extremities  are  on  a  much  lower  level,  an  element  of  gravity 
traction  is  present  in  some  instances,  while  the  support  of  the 
spine,  as  a  whole,  is  much  more  comprehensive  than  when  the 
body  lies  upon  a  plane  surface  (Fig.  32).  The  gradual  over- 
extension of  the  spine  by  bending  the  frame  in  this  manner  is 
so  definite  and  simple  that  it  may  l)e  easily  carried  out  by  the 
physician,  and  it  may  be  exaggerated  slightly,  to  compensate 
for  the  sagging  of  the  cover,  Thus,  it  is  far  more  effective 
than  any  form  of  padding  placed  on  a  flat  surface,  or  other 
form  of  support  with  which  I  am  familiar.  Upon  this 
frame  the  child  lies  constantly,  its  clothing  being  made  suffi- 
ciently large  to  include  the  apparatus,  thus  assuring  additional 
fixation.  Once  a  day  or  less  often,  the  child  is  removed 
from  the  frame  and  is  carefully  turned,  face  downward,  upon 
a  large  pillow;  the  back  is  then  inspected,  bathed  with 
alcohol  and  powdered,  and  the  apparatus  is  ther.  reapplied.  It 
is,  of  course,  desirable  to  have  two  equipped  frames,  but  this  is 
by  no  means  essential. 

The  effect  of  the  continued  fixation  upon  the  back  is  not  merely 
to  change  the  contour  of  the  spine,  but  of  the  entire  trunk  as  well; 
to  flatten  and  broaden  the  body.  This  increase  of  the  lateral 
at  the  expense  of  the  anteroposterior  diameter  is  quite  the  re- 
verse of  the  natural  tendency  of  the  deformity,  and  it  is,  there- 
fore, a  favorable  rather  than  an  unfavorable  eft'ect  of  the  treat- 
ment.    The  same  tendency  in  the  lower  region  may  be  checked 


72 


OE  TH  OPE  Die  S  UR  G  ER  Y 


by  the  use  of  a  flannel   binder,  such   as   is   ordinarily  worn    by 
infants. 

The  method  of  attaching  the  patient  to  the  frame  varies  some- 
what according  to  the  situation  and  character  of  the  disease. 
In  ordinary  cases,  as  has  been  stated,  a  canvas  apron,  similar  to 
that  used  with  the  back  brace  (Fig.  43),  is  applied,  and  is  buckled 
to  the  sides  of  the  frame.  If  advisable  the  shoulders  may  be 
held  down  by  bands  crossing  the  chest  or  by  axillary  straps  con- 
nected bv  a  chest  band.     If  still  more  effective  fixation  is  de- 


FiG  34 


A  perfect  cure  obtained  by  the  stretcher  treatment.     The  situation  of  the  disease 
is  shown  in  the  x-ray  picture,  Fig.  35. 

sired,  as  in  disease  of  the  upper  dorsal  region,  the  anterior  shoulder 
brace,  as  used  with  the  back  brace  (Fig.  41),  may  be  attached 
to  the  axillary  straps.  In  disease  of  the  upper  and  middle  re- 
gions of  the  spine  restraint  of  the  legs  is  not  necessary,  but  in 
lumbar  disease  a  broad  swathe  shoukl  be  passed  across  the  thighs, 
and  if  psoas  spasm  is  present  traction  may  be  employed. 

If   the    disease    is    of    the    upper  region  and  if  the  patient's 
head  is  of  the  long  type,  it  is  advisable  to  make  a  right  angular 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


73 


downward  bend  of  the  side  bars  above  the  seat  of  disease  so 
that  the  occiput  being  on  a  lower  level  the  proper  pressure  on 
the  spine  may  be  assured. 


Fig.  35 


An  x-ray  picture  of  the  case  (Fie.  34)  before  treatment.  The  .■situation  of  the  disease  at. 
the  junction  of  the  first  and  second  lumbar  vertebrae  is  indicated  by  the  lateral  deviation, 
and  by  the  approximation  of  the  dotted  lines  1  and  2  as  compared  to  the  others. 


74  OBTHOPEDIC  SUBGEEY 

In  disease  of  the  upper  region  of  the  spine  a  certain  amount 
of  traction  is  desirable  to  aid  in  the  reduction  of  deformity  and 
to  prevent  the  patient  from  raising  the  head.  This  traction  is 
usually  applied  by  means  of  the  halter  as  used  with  the  jury- 
mast.  The  straps  are  attached  to  a  crossbar  at  the  upper  ex- 
tremity of  the  frame,  and  traction  may  be  made  by  sunply  tighten- 
ing them;  or  if  the  upper  part  of  the  frame  is  somewhat  elevated, 
the  weight  of  the  patient's  body  makes  the  proper  countertrac- 
tion.  This  position  has  the  advantage,  also,  of  allowing  the 
patient  a  better  opportunity  to  see  what  is  going  on  about  him 
(Fig.  33). 

Fig.  36 


The  baby  carriage  as  used  in  hospital  practice  fbr  patients  on  the  stretcher  frame. 

In  disease  of  the  cervical  region  traction  is  usually  of  service 
and  fixation  of  the  head  is  always  indicated  in  addition  when 
the  occipitoaxoid  region  is  involved,  either  by  sand-bags  on 
either  side,  or,  preferably,  by  some  form  of  metal  brace. 

Greater  fixation  of  the  spine  may  be  desirable  in  cases  of  more 
acute  disease.  This  may  be  attained  by  the  use  of  a  light  back 
brace,  or  a  plaster  jacket,  in  connection  with  the  frame.  Such 
support  should  not  be  applied,  however,  until  the  recession  of 
deformity,  which  is  to  be  expected  under  treatment  by  the  hori- 
zontal fixation  and  overextension,  has  been  obtained    (Fig.  28). 

As  this  frame  is  simply  a  horizontal  brace  the  child  may  spend 
as  much  time  in  the  open  air  as  would  be  practicable  were  any 
other  appliance  used. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


75 


Personally  I  have  never  seen  other  than  favorable  results  from 
this  method  of  treatment.  Pain  and  discomfort  are,  as  a  rule, 
relieved  almost  immediately,  and  there  is  a  corresponding  im- 
provement in  the  general  condition  of  the  patient.  Meanwhile 
the  growth  of  the  trunk,  which  is  so  often  checked  by  the  disease 
and  by  the  deformity,  appears  to  progress  with  normal  rapidity, 
so  that  the  apparatus  may  be  actually  outgrown  before  the  ter- 
mination of   this  part  of  the  treatment.      Horizontal  fixation  is, 

Fig.   37 


The  Taylor  l)race.aiul  head  support  applied  for  disease  of  the  upper  dorsal  region. 

of  course,  a  treatment  not  complete  in  itself,  since  it  must  be  sup- 
plemented by  the  usual  supports  when  the  erect  attitude  is 
again  assumed.  Its  duration  varies  from  six  to  eighteen  months. 
The  indications  for  its  discontinuance  are  the  correction  of  de- 
formity, the  apparent  quiescence  or  cure  of  the  local  disease  as 
indicated  by  the  physical  signs,  and  by  the  behavior  of  the  patient, 
who,  as  repair  advances,  becomes  restless  when  removed  from 
the  frame,  evidently  desiring  to  sit  and  to  stand. 


76 


ORTHOPEDIC  S UR GER Y 


At  this  stage  it  is  well  to  apply  the  ambulatory  support  some 
time  before  the  patient  is  released  from  the  frame,  allowing  little 
by  little  the  changes  in  attitude  and  habits.  If  the  plaster  jacket 
is  to  be  used  it  may  be  applied  during  longitudinal  suspension 
or  otherwise,  after  which  the  child  is  immediately  replaced  upon 
the  frame,  where  the  plaster  is  allow^ed  to  harden;  thus  it  holds 
the  spine  in  an  attitude  to  which  it  has  become  accustomed. 
(Fig.  63). 

Ambulatory  Supports. — The  two  types  of  ambulatory  sup- 
ports are  the  steel  brace  and  the  plaster  jacket. 

The  Back  Brace. — The  spinal  brace,  or  spinal  assistant,  as  the 
original  appliance  of  Dr.  C.  F.  Taylor  was  called,  consists  essen- 
tially of  two  steel  bars  that  are  applied  on  either  side  of  the 
spinous  processes  from  the  top  to  the  bottom  of  the  spine.  At  the 
seat  of  the  disease  pads  are  placed  to  provide  for  greater  pressure 
and  fixation,  and  to  form  a  fulcrum  over  which  the  spine  may  be 
straightened  or  held  erect,  when  the  two  extremities  of  the  brace 
firmly  attached   to  the  pelvis  and  to  the  shoulders.     The 

attaclunent  at  the  lower  end  is  made 
by  means  of  a  pelvic  band  of  sheet 
steel  (gauge  18)  from  one  and  a  half 
to  two  inches  in  width,  long  enough 
to  reach  from  one  iliac  spine  to  the 
other;  it  is  placed  as  low  as  possible 
on  the  pelvis;  in  other  words,  just 
above  the  upper  extremities  of  the 
trochanters.  To  this  the  uprights 
are  firmly  attached  at  an  interval  of 
from  one  and  a  quarter  to  one  and 


are 


Fig.  39 


The  Taylor  back  brace.    (11.  L.  Taylor.) 


Tlie  Taylor  chest  piece.     Two  triangular  pads 
of  hard  rubber  connected  by  a  bar. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


77 


three-quarter  inches  from  one  another,  so  that  the  spinous 
processes  may  pass  between  them,  while  pressure  is  made 
on  the  lateral  masses  of  the  vertebrae.  The  uprights  are 
made  of  varying  strength,  according  to  the  age  of  the 
patient,  usually  about  one-half  an  inch  in  width  (of  gauge 
8  to  12)  and  of  such  quality  of  steel  that,  although  unyielding 
to  the  strain  of  use,  it  may  be  readily  bent  by  wrenches,  and  thus 
accurately  adjusted  to  the  back.  The  uprights  reach  to  the 
root  of  the  neck,  or  to  about  the  level  of  the  second  dorsal  ver- 


FiG.  40 


Fig.  41 


Backward   traction  on  the  shoulder  fixes  the 
upper  dorsal  region. 


The  anterior  shoulder  brace  and  its 
attachment. 


tebra;  from  this  point  two  short  arms  of  metal  project  forward 
and  outward  on  either  side  of  the  neck,  reaching  to  about  the 
middle  of  the  clavicles.  To  these,  padded  shoulder  straps  are 
attached,  which  pass  through  the  axillje  to  a  crossbar  on  the 
back  brace;  thus  downward  pressure  on  the  shoulders  is  avoided 
and  increased  leverage  is  assured  (Fig.  37). 

Opposite  the  area  of  disease  two  strips  of  thin  steel  about  three 
inches  in  length  are  fixed;  these  are  slightly  wider  than  the  up- 
rights and  are  perforated  for  the  attaclmient  of  the  pressure  pads, 
which  may   be  made  of  layers  of  canton  flannel  or  felt,  or  un- 


78  OR THOPEBIG  SURGERY 

yielding  material,  such  as  leather  or  hard  rubber,  may  be  used 
instead.  The  pads  should  project  from  a  quarter  to  a  half -inch 
in  front  of  the  uprights  in  order  that  firm  and  constant  pres- 
sure, to  the  extent  tha't  the  skin  will  tolerate,  may  be  made  at 
the  seat  of  disease  (Fig.  38). 

In  measuring  for  this  brace  the  patient  is  placed  in  the  prone 
posture  and  a  tracing  of  the  outline  of  the  back  is  made  by  means 
of  the  lead  tape.  This  outline  may  be  cut  in  cardboard  and 
fitted  to  the  back;  in  fact,  if  the  mechanic  is  unfamiliar  with 
the  work,  each  part  of  the  brace,  uprights,  pelvic  band,  etc., 
may  be  cut  in  cardboard  and  attached  to  one  another  to  serve 
as  a  model.  Before  the  brace  is  finished  it  should  be  applied 
to  the  back  and  should  be  adjusted  carefully  by  means  of  wrenches. 
The  pelvic  band  and  the  parts  that  come  in  direct  contact  with 
the  skin  are  usually  covered  with  leather,  or,  in  the  treatment 
of  young  children,  with  rubber  plaster  and  canton  flannel  to 
prevent  rusting. 

If  the  brace  is  applied  before  the  stage  of  deformity  it  should 
follow  the  exact  shape  of  the  spine,  but  if  deformity  is  present, 
particularly  in  disease  of  the  thoracic  region,  it  should  be  made 
somewhat  straighter,  in  order  to  permit  a  gradual  correction 
of  the  compensatory  lordosis  in  the  lumbar  region,  and  for  in- 
creased leverage  above  the  deformity.  As  has  been  stated,  a 
certain  amount  of  recession  of  deformity  can  be  obtained  by 
rest  in  the  horizontal  position,  and  if  practicable  this  unproved 
contour  should  be  attained  before  the  brace  is  applied.  The 
apparatus  is  held  in  place  by  an  "apron"  (Fig.  43),  which  covers 
the  chest  and  abdomen,  to  which  straps  are  attached.  Ordin- 
arily this  is  made  of  strong  linen  or  cotton  cloth,  but  a  canvas 
front  shaped  accurately  to  the  body  and  strengthened  with 
whalebone,  is  a  more  comfortable  and  efficient  support.  In 
applying  the  brace  the  pelvic  band  is  first  attached  to  the 
apron,  then  the  straps  in  order,  from  below  upward,  and,  finally, 
the  shoulder  straps.  Each  strap  is  tightened  until  the  brace  is 
firmly  fixed  in  proper  position.  When  a  brace  is  properly  applied 
and  properly  fitted  it  holds  its  place  l)y  friction,  but  when  the 
disease  is  of  the  lower  lumbar  region,  or  if  the  brace  has  a 
tendency  to  upward  displacement  perineal  straps  should  be  used 
to  hold  the  pelvic  band  firmly  in  its  place  (Fig.  3.S).  At  first 
the  brace  is  removed  once  a  day  in  order  to  wash  and  powder 
the  back,  the  same  care  being  observed  in  moving  the  child  as 
in  the  treatment  by  the  frame;  but  when  the  skin  has  become 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


79 


accustomed  to  the  pressure  the  brace  should  be  removed  only  at 
infrequent  intervals,  and  thus,  if  desirable,  only  under  the  super- 
vision of  the  surgeon. 

This  description  indicates  the  essential  qualities  of  the  back 
brace.  It  has  been  modified  in  various  ways;  for  example,  Dr. 
Taylor  long  since  discarded   the  straight  pelvic  band   in   favor 


Fig.    42 


The  Taylor  back  brace  and  head  support  combined  with  the  Whitman  anterior  support. 

of  one  of  a  U-shape  (Fig.  38).  This  makes  the  brace  somewhat 
lighter  and  relieves  the  sacrum  from  pressure,  but  it  does  not 
add  to  its  effectiveness.  The  efficiency  may  be  increased,  how- 
ever, by  improving  the  attachment  at  its  upper  extremity,  as 
is  illustrated  in  Fig.  39,  in  which  two  triangular  pads  of  hard 
rubber  connected  by  a  metal  bar  are  employetl. 

This  is  an  improvement  on  the  simple  shoulder  straps  of  the 
original  brace,  but  it  does  not  provide  the  quality  of  support  and 
fixation   that   is   desirable   when   the   disease  is  of  the  upper  or 


80 


ORTHOPEDIC  SURGERY 


middle  segment  of  the  thoracic  region.  In  such  cases  the  upper 
part  of  the  chest  is  flattened,  the  inclination  of  the  ribs  is  increased, 
and  the  shoulders  droop  forward,  carrying  with  them  the  scapulae. 
Thus,  the  weight  and  the  strain  of  the  motion  and  use  of  the  arms 
tend  to  increase  the  deformity. 

In  Health  direct  forward  or  reaching  movements  of  the  arms 
are  always  accompanied  by  an  increase  in  the  posterior  curvature 
of  the  dorsal  spine.     On  the  other  hand,  if  the  shoulders  are 


Fig 


Fig.  44 


The  anterior  shoulder  brace. 


The  scapular  pads. 


drawn  backward  and  held  in  this  attitude,  the  curvature  of  the 
spine  is  lessened  and  the  chest  is  elevated  and  expanded  (Fig. 
40). 

In  the  treatment  of  disease  of  the  upper  dorsal  region  it  should 
be  the  aim,  in  the  application  of  a  brace,  to  follow  this  indication 
and  to  apply  pressure  directly  upon  the  extremities  of  the  shoulders 
to  assure  the  greatest  possible  fixation  of  the  spine  and  to  restrain 
the  movements  of  the  arms  that  tend  to  increase  the  deformity. 

The  diagrams  illustrated  in  Fig.  41  show  how  such  support 
may  be  apj)li('d.  '^l.Vo  saucer-shaj)ed  plates  of  hard  rubber  or 
padded  metal  (Fig.  42)  cover  the  heads  of  the  humeri  and  are 
joined  by  a  rigid  bar  of  steel,  which  passes  across  but  does  not 
touch  the  chest.    On  the  back  brace  are  placed  two  triangular  pads 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


Fig.  40 


of  similar  construction,  which  cover  and  press  upon  the  scapulae. 
These  pads  are,  however,  not  essential  and  are  often  omitted. 
The  back  brace  is  applied,  the  shoulders  are  then  drawn  back- 
ward and  the  shoulder-cups  are  firmly  attached  by  straps  to  the 
neck  bars  of  the  brace  above,  and  by  axillary  bands  below  in 
the  usual  manner.  By  this  means  the  thorax  is  elevated  and 
the  spine  is  more  effec- 
tively fixed,  while  direct 
movement  of  the  arms 
forward  is  made  impos- 
sible. It  would  seem 
that  such  restraint  would 
be  irksome  to  the  patient, 
but  in  an  extended  use 
of  the  apparatus  this  has 


The  loop  heatl  support. 


Disease  of  the  middle  cervical  rerion,  showing 
the  deformity  and  attitude.  Tliis  patient  had  been 
paralyzed  for  one  year  before  treatment  was  begun. 
(See  Fig.  47.) 


never  caused  complaint-  In  many  instances,  even  when  the  dis- 
ease is  as  low  as  the  tenth  dorsal  vertebra,  it  may  be  used 
with  advantage,  but  it  is  especially  indicated  when  the  disease 
is  in  the  neighborhood  of  the  seventh  dorsal  vertebra.  In  con- 
nection with  the  shoulder  brace  it  is  usually  advisable  to  ajiplv 
a  support  beneath  the  chin  to  prevent  the  forward  inclination 
of  the   neck   and   to  tilt  the  head  somewhat  backward.     A    very 

6 


82  ORTHOPEDIC  SURGERY 

simple  and  inoffensive  support  of  this  character  is  a  loop  of 
steel  surrounding  the  neck  and  attached  by  screws  to  a  back 
bar  on  the  brace  (Fig.  45).  If  a  more  efficient  brace  is  required, 
as  when  the  disease  is  of  the  upper  dorsal  or  cervical  regions, 
the  Taylor  head  support  should  be  used.  This  is  an  oval 
ring  of  steel  which  may  be  clasped  about  the  neck  by  means 
of  a  lateral  hinge.  On  the  front  a  cup  of  hard  rubber  sup- 
ports the  chin  and  behind  the  ring  fits  upon  an  upright  pivot 
that  may  be  raised  or  lowered  upon  a  crossbar  on  the  upper 
part  of  the  brace;  free  lateral  motion  is  allowed,  or  it  may  be 
checked  by  means  of  a  screw  (Fig.  47). 

If  absolute  fixation  of  the  head  is  indicated,  as  in  disease  at 
or  near  the  occipitoaxoid  region,  two  steel  uprights  may  be  at- 
tached to  the  back  of  the  ring;  these  are  bent  to  fit  the  posterior 
and  lateral  aspect  of  the  head  closely,  and  a  band  of  webbing 
is  passed  from  one  upright  to  the  other  and  about  the  forehead. 

In  applying  the  support  the  chin  should  always  be  tilted  slightly 
upward  in  order  to  throw  the  weight  of  the  head  backward 
(Fig.  47).  The  adjustment  of  the  head  support  is  made  easier 
if  the  pivot  is  attached  to  the  upright  by  means  of  a  ball-and- 
socket  joint  (Shaffer)  (Fig.  37)  that  may  be  regulated  by  a  screw 
and  key;  this  arrangement  is  of  service  when  the  head  is  dis- 
torted, but  it  is  by  no  means  necessary. 

When  the  Taylor  head  support  or  similar  appliance  is  used 
the  greater  part  of  the  pressure  is  sustained  by  the  chin,  which 
may,  after  a  time,  undergo  an  unsightly  recession.  It  may  be  of 
advantage,  therefore,  in  such  cases,  and  particularly  when  restraint 
of  the  motion  of  the  neck  is  desirable,  to  transfer  this  pressure  to 
the  forehead  and  occiput  by  extending  the  back  bars  upward 
over  the  back  of  the  head,  as  in  Fig.  54. 

A  jury-mast  may  be  used  to  support  the  head  also;  its  adjust- 
ment will  be  described  in  connection  with  the  plaster  jacket,  with 
which  it  is  usually  associated  (Fig.  48). 

The  Plaster  Jacket. — It  was  claimed  at  one  time  that  a  plaster 
jacket  applied  while  the  body  was  partially  suspended  would 
actually  relieve  the  weakened  area  of  superincumbent  weight  by 
holding  the  diseased  surfaces  apart.  This  is  not  the  fact.  The 
jacket  supports  the  spine  as  does  the  brace  by  holding  it  in  the 
erect  or  extended  position.  One  is  a  circular  and  the  other  is  a 
posterior  splint.  There  is  this  difference,  however:  the  brace 
fits  the  spine  accurately  and  holds  its  place  by  pressure  and  friction ; 
the  jacket  is  held  in"place  by^the  support  of  the  projecting  pelvic 


TUBERCULOUS  DISEASE  OF  THE  SPJNE 


83 


bones;  it  lacks  the  accuracy  of  adjustment  of  the  brace  at  the 
seat  of  disease,  but,  on  the  other  hand,  it  provides  a  solid  support 
on  the  front  and  sides  of  the  body. 

Each  appliance  has  advantages  and  disadvantages  that  become 
apparent  in  the  treatment  of  certain  phases  of  the  disease  or  con- 
ditions of  the  patient. 


Fig.  47 


Fig.  48 


The  Taylor  brace  and  head  support,  apphed 
to  the  jiatient  .shown  in  Fig.  46. 


The  Taylor  brace  with  jury-mast. 


The  plaster  bandage  is  a  simple  support,  whose  efficiency 
depends  upon  the  accuracy  of  its  adjustment  to  the  irregularities 
of  the  body,  and  upon  the  leverage  that  it  exerts  above  and  below 
the  weakened  part.  It  shoukl  be  applied  while  the  body  is  held 
in  the  best  possible  position;  its  inner  surface  should  be  smooth, 


84  OR THOPEDIC  S UR GER Y 

and    the    bony    prominences  that  are  exposed    to    friction    and 
pressure  should  be  protected. 

A  seamless  shirt  should  be  worn;  these  are  made  in  several 
sizes  and  are  sold  by  the  yard  at  a  low  price.  The  shirt  should  fit 
the  body  closely  and  should  be  long  enough  to  reach  to  the  knees. 
On  the  front  and  back  bands  of  linen  or  China  silk  or  other 
material,  about  three  inches  in  width  and  three  feet  in  length, 
should  be  placed  beneath  the  shirt.  These  bands,  or,  as  Lorenz 
calls  them,  "scratchers,"  are  for  the  purpose  of  keeping  the  skin 
clean.  The  patient  is  then  placed  upon  a  stool,  and  the  halter  of 
the  suspension  apparatus  is  carefully  adjusted;  the  arms  are  ex- 
tended over  the  head  and  the  hands  clasp  the  straps  or  rings; 
thus,  the  chest  is  expanded  to  its  full  limit.  Sufficient  tension 
is  made  upon  the  rope  to  partially  suspend  the  body  and  to  draw 
the  spine  into  the  best  possible  attitude;  in  most  instances  the 
heels  should  be  slightly  lifted  from  the  stool. 

Dr.  SajTe,  to  whom  we  are  indebted  for  the  exposition  of  this 
valuable  means  of  treatment,  insisted  that  the  sensations  of  the 
patient  should  be  the  guide  and  that  traction  should  be  made 
only  to  the  point  of  comfort.  This  is  a  valuable  indication  in 
the  treatment  of  the  adult,  but  it  is  not  often  of  service  in  child- 
hood. 

Before  applying  the  plaster  bandage  pieces  of  piano  felting  or 
similar  material  of  sufficient  thickness  are  placed  about  the  anterior 
pelvic  spines,  over  the  upper  part  of  the  sternum,  and  a  thin 
strip  is  sometimes  used  to  cover  the  spinous  processes.  Finally 
long  pads  of  saddler's  felt,  or  of  other  material  of  sufficient  thick- 
ness, are  applied  on  either  side  of  the  prominent  spinous  pro- 
cesses to  protect  them  from  friction  and  to  provide  greater  pres- 
sure and  fixation  at  the  seat  of  disease.  In  the  treatment  of 
adolescent  or  adult  females  the  breasts  should  be  covered  with 
a  layer  of  cotton,  which  may  be  removed  later  if  necessary, 
to  prevent  pressure.  The  "dinner  pad"  is  now  not  often  used, 
except  in  the  treatment  of  adults  and  in  certain  cases  in  which 
the  abdomen  is  retracted.  In  childhood  the  abdomen  is  usually 
prominent,  and  in  most  instances  no  extra  space  is  required. 
Occasionally,  however,  one  is  told  that  the  patient  complains 
of  discomfort  after  meals,  evidently  due  to  constriction,  and  in 
such  cases  proper  allowance  must  be  made.  The  pad,  which 
is  supposed  to  represent  the  space  necessary  after  a  full  meal, 
is  made  by  folding  a  small  towel  into  the  shape  of  a  sandwich; 
this  is  attached  to  a  bandage  and  is  placed   beneath  the  shirt 


TUBERCULOUS  DISEASE  OF  2 HE  SPINE  85 

just  below  the  ensiform  cartilage;  when  the  jacket  is  completed 
it  may  be  drawn  out  by  means  of  the  hanging  bandage,  leaving 
the  additional  space  for  emergencies. 

The  materials  for  the  jacket  should  be  of  the  best.  Fresh 
dental  plaster  should  be  rubbed  by  hand  into  strips  of  crinoline, 
free  from  glue.  The  bandages '  should  be  from  three  to  five 
inches  in  width  and  six  yards  in  length,  from  three  to  six  being 
required  for  a  jacket,  according  to  the  size  of  the  child.  They 
should  be  placed  on  end,  in  a  pail  of  warm  water,  one  at  a  time 
as  they  are  used.  No  salt  or  alum  should  be  used  to  hasten  the 
setting  of  the  plaster;  in  fact,  if  such  aid  is  necessary  it  is  unfit 
for  use.  When  the  Inibbles  have  ceased  to  rise  the  })andage  is 
squeezed  gently  until  no  water  drips  from  it,  and  the  loose  threads 
are  removed  from   the  ends. 

One  person  should  sit  behind  the  patient  and  one  in  front, 
while  the  third  may  hold  the  rope  and  check  the  swaying  of  the 
body.  The  one  who  sits  behind  the  patient  may  clasp  the  child's 
legs  between  his  knees  and  thus  assure  better  fixation  of  the 
pelvis.  The  pads  are  held  in  position  until  they  are  fixed  by  the 
plaster  bandages,  which  should  be  applied  with  a  slight  and  even 
tension. 

II  As  a  rule,  the  jacket  should  be  of  uniform  thickness  through- 
out. This  thickness  need  not  exceed  one-eighth  to  one-fourth  of 
an  inch,  and  it  may  even  be  lighter  in  certain  cases.  It  is  well 
to  make  the  first  turns  about  the  waist,  and  to  use  the  first  band- 
age about  the  pelvis,  since  the  pelvis  is  the  base  of  support;  and, 
as  the  most  important  point  for  counterpressure  is  the  chest,  this 
part  should  be  made  especially  strong  and  resistant. 

During  the  application  of  the  jacket  it  should  be  rubbed  con- 
stantly in  order  that  the  different  layers  of  ^bandage  may  adhere 
to  one  another,  and  that  it  may  fit  the  projections  of  the  pelvis 
and  body  closely.  Meanwhile  the  attitude  of  the  patient  should 
be  carefully  watched,  in  order  to  prevent  lateral  inclination  of 
the  body.  In  some  instances  it  is  possible  to  lessen  the  deformity 
by  the  extension  and  by  backward  traction  on  the  shoulders  and 
forward  pressure  on  the  trunk  while  the  jacket  is  hardening. 

Wlien  the  jacket  is  nearly  firm  it  should  be  ti'immed.  In  many 
instances  this  may  be  done  while  the  patient  is  in  the  swing,  but 
if  he  is  fatigued  he  may  be  placed  in  the  recumbent  posture. 

As  a  rule,  the  front  of  the  jacket  should  reach  from  the  upper 
margin  of  the  sternum  to  the  pubes;  behind,  from  about  the 
midline  of  the  scapuhe  to  the  gluteal  fold;  laterally,  it  should  be 


86 


ORTHOPEDIC  SURGERY 


cut  away  sufficiently  to  prevent  cliafing  of  the  arms;  and  on  either 
side  of  the  pubes  an  oval  section  is  cut  out,  to  allow  for  the  flexion 
of  the  thighs  in  the  sitting  posture.  Particular  attention  is  called 
to  the  importance  of  making  the  jacket  as  long  as  possible,  so 
that  the  abdomen  may  be  contained  within  it  instead  of  being 


f'iG.  49 


Fig.  50 


'J'he  (jlaster  jaf^kot,  illiist  ral-iiiK  the 
arrari»?f;rjierit  of  the  whirt. 


The  plaster  jacket  supiJortiiig  the  abdoincn. 
The  cleansing  bandagea  are  not  nhowii. 


forced  out  beneath  its  lower  border  (Fig.  50).  After  the  appli- 
cation of  the  jacket  the  patient  should  remain  in  the  recumbent 
posture  for  at  least  half  an  hour  or  longer,  as  it  does  not  become 
absolutely  firm  for  several  hours.     'J'lie  shirt  is  then  drawn  up  over 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


87 


the  jacket  and  is  sewed  to  the  neck'portion ;  this  adds  much  to  neat- 
ness and  cleanliness.  The  shirt  must  })e  drawn  tightly  about  the 
neck,  in  order  to  guard  the  body  from  the  crumbs  or  other  objects 
that  may  fall  beneath  the  jacket,  and  in  many  instances  a  special 
protector  in  the  form  of  a  wide  collar  bib  may  be  used  with 
advantage. 

The  upper  and  lower  ends  of  the  cleansing  bandages  are  joined 
to  one  another  with  tape,  and  with  them  the  skin  is  carefully 
rubbed  twice  daily.     When  soiled  they  may  be  replaced. 

Fir:.   51 


The  jury-mast  and  the  anterior  support. 

It  may  be  mentioned  in  this  connection  that  even  the  slightest 
excoriation  or  irritation  of  the  skin  beneath  the  jacket  can  be 
detected  by  the  peculiar  odor.  Of  this  parents  should  be  in- 
formed, so  that  it  may  be  cut  down  and  the  source  of  the  irritation 
removed  at  once.  With  ordinary  care  'sores,"  the  bugbear  of 
the  plaster  jacket,  may  be  avoided  or  so  quickly  detected  that 
they  are  of  little  consequence. 

If  the  disease  is  of  the  middle  region  of  the  spine,  backward 
traction  on  the  shoulders  is  indicated  by  means  of  the  anterior 
shoulder   brace  described    in  connection  with  the  spinal    brace 


88 


ORTHOPEDIC  SUHGEBY 


(Fig.  50;  or,  if  this  is  not  at  hand,  padded  straps  may  be  passed 
about  the  shoulders  and  attached  to  buckles  placed  on  the  back 


Fig.  52 


IlluHtraling  fixation  of  the  head  in  the  overextended  attitude. 

of  the  jacket.     Traction  applied  in  this  manner  aids  in  prevent- 
ing deformity  and  assures  better  expansion  of  the  chest. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


89 


In  many  instances  a  head  support  is  reciiiired,  and  it  is,  of 
course,  always  indicated  in  disease  of  the  upper  dorsal  and  cer- 
vical regions.  For  this  purpose  a  jury-mast  or  a  posterior  sup- 
port may  be  employed. 

The  jury-mast  should  be  of  tempered  steel,  strong  enough  to 
hold  its  shape  under  the  tension  of  the  halter  (Fig.  52).  Its  base 
should  be  incorporated  firmly  in  the  jacket  below  the  seat  of  the 


Fig.   54 


Fig.  55 


A  fixation  .support  for  the  head. 
This  may  be  used  with  the  brace  or 
with  the  jacket. 


Front  view  of   the  same  patient. 


disease;  it  should  be  long  enough  to  reach  well  above  the  head, 
and  the  crossbar  should  be  placed  directly  over  the  ears  (Fig.  50). 
The  halter  should  be  applied  with  as  much  tension  as  can  be 
borne  comfortably  by  the  patient,  so  that  the  weight  of  the  head 
may  be  at  least  partly  supported.  The  straps  should  be  ad- 
justed to  tilt  the  chin  slightly  upward,  the  aim  being  to  draw  the 
head  backward  and  thus  to  extend  the  spine.     In  disease  of  the 


90  OBTHOPEDIC  SURGERY 

cervical  region  the  crossbar  should  be  fixed  to  check  lateral  mo- 
tion of  the  head,  but  this  is  unnecessary  when  the  disease  is  at 
a  lower  level. 

If  more  complete  fixation  of  the  head  is  desired,  or  if  the  jury 
is  ineffective,  an  appliance  similar  to  that  shown  in  Fig.  51  may 

Fig.  56 


The  jacket  and  jury-mast  apijlied.     The  same  patient  is  sh<jwn  in  Fig.  .33. 

be  used.  This  consists  of  two  light  steel  bars,  incorporated  like 
the  jury-must  in  the  jacket,  and  adjusted  to  the  neck  and  back 
of  the  head.  Their  upper  extremities  are  joined  by  a  band  of 
light  steel  of  U-shape,  long  enough  to  reach  from  ear  to  ear,  the 
circumference  being  completed  l)y  a  band  of  tape  across  the  fore- 
head. In  certain  instances  additional  straps  may  be  placed  be- 
neath the  chin  and  the  occiput,  as  in  Figs.  54  and  55.  In  this 
connection  it  may  be  stated  that  the  suj)[)ort  provided  by  the  jury- 
mast  is  only  effective  when  it  is  carefully  adjusted  and  carefully 
watched.  In  most  instances,  therefore,  a  rigid  apparatus,  though 
less  comfortable,  is  to  Ix;  preferred. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


91 


The  Application  of  the  Jacket  in  the  Recumbent  Posture. — The 
jacket  may  l)e  applied  wliile  the  patient  hes  extended  in  the  prone 
posture,  by  the  hammock  method  suggested  by  Davy,  of  London. 

A  long  narrow  strip  of  cotton  cloth  is  passed  under  the  shirt 
and  is  drawn  tight  enough,  by  means  of  a  pulley  or  by  manual 
traction,  to  support  the  child  in  the  proper  attitude,  preferably, 
of  course,  in  overextension.  An  opening  is  cut  for  the  face,  and 
if jC advisable,  traction  may  be  made  on  the  arms  and  legs  of  the 
patient.  The  bandages  are  then  applied  in  the  ordinary  maimer, 
after  which  the  cloth  may  be  cut  short  at  one  end  and  removed 

Fig.  57 


The  ap!>licati(jii  of  the  jacket  in  the  recumbent  i)()stuie  by  means  of  the  Goldthwait 
appUance:  A,  the  support,  similar  to  that  upon  which  the  patient  is  lying;  B,  two  thin 
bands  of  steel,  similar  to  those  used  in  the  Taylor  brace. 

This  method  is  of  service  in  the  treatment  of  weak  or  para- 
lyzed patients,  but  the  adjustment  is  somewhat  less  satisfactory 
than  by  the  ordinary  method  in  that  the  fixation  of  the  thorax 
is  less  accurate.  The  jacket  may  be  applied  in  the  supine  posture 
by  means  of  the  Goldthwait  apparatus.  This  may  be  employed 
with  advantage  in  the  routine  application  of  the  plaster  jacket, 
and  it  has  supplanted  in  some  degree  the  suspension  method. 

It  consists  essentially  of  a  support  (Fig.  57)  carrying  on  its 
upper  extremities  two  thin  strips  of  perforated  metal.     To  these 


92 


OR THOPEDIC  SURGERY 


strips  felt  is  attached,  forming  pads  similar  to  those  used  on  the 
back  brace.  The  patient  is  then  placed  with  his  back  resting  on 
the  pads  at  the  seat  of  the  disease.  The  buttocks  and  the  head 
are  allowed  to  sink  downward  to  the  point  of  toleration;  thus  an 
extending  force  is  exerted  on  the  spine.  The  plaster  bandages 
are  then  applied  in  the  usual  manner  about  the  body  on  either 
side  of  the  support.  When  it  is  completed  the  patient  is  lifted 
from  the  support,  the  pads  being  included,  of  course,  in  the  jacket. 


Fig.  5S 


R  Tunstall  Taylor's  apparatus  for  the  application  of  the  plaster  jacket  in  the  recum- 
bent posture,  consisting  of  an  adjustable  back  suppoit  and  pelvic  rest  connected  by  a 
sliding  bar.    (See  Fig.  59.) 

Fic.  59 


The  Taylor  appliance  in  use,  showing  the  h.vperextension  of  the  spine.  The  plaster 
jacket  having  been  applied,  the  back  rest  is  removed  by  pressing  the  bandages  from 
side  to  side  or  by  enlarging  tiie  oi)ening.  If  desirable,  the  defect  is  then  concealed  by 
a  turn  of  pla.ster  bandage. 

An  opening  remains  at  this  point  that  may  be  closed  by  an  addi- 
tifjiial   })anrhige. 

Other  supports  of  a  similar  nature  are  in  use,  but  as  they  do 
not  differ  from  it  in  principle  a  detailed  description  is  unneces- 
sary (Figs.  58  and  59). 

If  the  deformity  is  of  recent  origin  it  may  be  actually  corrected 
by  the  leverage  exerted,  but  in  most  instances  the  hyperextension  * 
takes  place  in  the  unaffected  parts  of  the  spine,  particularly  in 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


93 


the  lumbar  regions.  Thus  the  correction  is  apparent  rather 
than  actuah  In  order  to  prevent  this  and  to  exert  more  effective 
leverage  on  the  deformity  Goldthwait  uses  the  apparatus  illus- 
trated in  Fig.  60. 


Fig.  60 


Goldthwait's  portable  frame  for  applying  the  plaster  jacket. 
Fig.  61 


The  plaster  jacket  applied  in  .supine    posture  by  means  of    the   Met zger-Goldth wait 

apparatus. 

The  patient  lies  on  two  malleable  steel  bars  fitted  to  tlie  lumbar 
region  reaching  only  to  the  apex  of  the  deformity.  The  plaster 
bandages  forming  the  lov^'er  part  of  the  jacket  having  been  ap- 
plied the  upper  portion  of  the  trunk  is  allowed  to  sink  downward 
to  the  point  of  toleration  and  the  jacket  is  then  completed.  The 
steel  bars  which  have  prevented  the  ujjward  arching  of  the 
lumbar  region  of  the  spine  are  then  withdrawn.     The  Metzger 


94 


ORTHOPEDIC  SURGERY 


apparatus,  of  whicli  that  last  described  is  an  adaptation,  which 
permits  longitudinal  traction  as  well  as  direct  leverage,  is  shown 
in  Figs,  61  and  62. 

The  Application  of  the  Jacket  to  Patients  Who  Have  Been  Treated 
on  the  Stretcher  Frame. — A  satisfactory  method  of  applying  a 
plaster  jaclcet  to  young  subjects,  when  the  deformity  has  been 
corrected  in  whole  or  in  part  by  recumbency  on  the  frame  in  the 
overextended  position,  is  the  following :  The  patient  is  suspended 
face  downward  in  the  horizontal  position  by  two  assistants,  one 
holding  the  arms  and  the  other  the  thighs;  thus,  a  certain  amount 
of  traction  is  exerted,  while  the  weight  of  the  body  tends  to  over- 
extend  the  spine. 

In  this  attitude  a  jacket  is  quickly  applied,  and  the  child  is  at 
once  replaced  upon  the  frame,  which  has  been  protected  by  a 
rubber  sheet  (Fig.  62).   The  plaster  jacket,  during  the  hardening 

Fig.  62 


The  stretcher  frame  on  which  the  patient  is  replaced  while  the  jacket  is  hardening 

process,  must  conform  to  the  habitual  posture  of  recumbency. 
The  pressure  pads  of  the  frame  indent  the  bandage  on  either 
side  of  the  .spinous  processes  (Fig.  63),  and  thus  afford  better 
support  and  fixation.  This  is  a  very  satisfactory  method  of  ap- 
plying tiie  jacket  in  this  class  of  cases,  because  it  is  not  neces- 
sary to  retain  the  child  in  an  uncomfortable  position  while  the 
bandage  is  hardening,  and  l)ecause  accuracy  of  adjustment  in 
the  l)est  possible  attitude  is  assured. 

For  the  routine  application  of  the  ])laster  jacket  vertical  sus- 
pension is  t)  be  preferred,  because  in  this  attitude  the  support 
may  be  more  accurately  adjusted.  The  hammock  method  and 
that  just  described  are  of  particular  service  in  the  treatment  of 
young  subjects.  ''J'he  supine  posture  may  be  selected  with  advan- 
tage when  the  spine  is  sufficiently  flexible  at  the  seat  of  disease 
to  permit  a  certain  degree  of  correction  or  if  the  patient  is  weak 
or  timid. 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


95 


As  a  rule,  a  jacket  may  be  worn  for  two  months,  although  not 
infrequently  it  may  remain  for  six  months,  or  even  longer,  and 
yet  be  fairly  efficient.  Usually  one  jacket  is  removed  and  an- 
other applied  on  the  same  day,  but  if  the  skin  is  at  all  sensitive 
it  is  well,  after  the  washing  and  powdering,  to  reapply  the  old 
jacket,  closing  it  with  adhesive  plaster,  and  allow  an  interval  of 
a  few  days  before  applying  the  permanent  one. 


Fig.  63 


Jacket  applied  by  the  stretcher  method,  showing  the  depressions  on  either  side 
caused  by  the  frame  pads. 

The  Plaster  Corset. — In  the  stage  of  recovery  the  jacket  may 
be  replaced  by  a  corset.  A  jacket,  matle  and  trinnned  as  already 
described,  is  cut  down  the  centre  and  removed  from  the  body. 
It  is  carefully  readjusted  to  its  former  shape,  bandaged  ■\\itli  the 
cut  surfaces  in  close  apposition,  and  is  thoroughly  dried  or  baked. 

All  wrinkles  are  then  cut  away  from  the  inner  surface,  and 
extra  padding  is  applied  if  necessary;  the  shirt  is  drawn  tightly 
about  the  borders  of  the  jacket  and  strips  of  leather  provided 
with  hooks  are  sewed  in  front  so  that  it  may  be  laced  like  an 
ordinary  corset.  It  may  be  removed  from  time  to  time  to  allow 
for  bathing,  but  it  should  always  be  removed  and  reapplied  while 
the  patient  is  suspended  or  in  the  recumbent  position. 


96  ORTHOPEDIC  SURGERY 

The  corset  is  sometimes  used  in  place  of  the  jacket  during  the 
active  stage  of  the  disease,  but  it  is  less  effective,  since  the  repeated 
stretching  during  removal  and  reapplication  weakens  the  appli- 
ance and  impairs  the  accuracy  of  adjustment.  In  addition,  one 
of  the  strongest  arguments  in  favor  of  the  use  of  plaster  of  Paris, 
that  treatment  is  under  the  control  of  the  surgeon,  is  nullified. 

Comparison  of  the  Two  Forms  of  Ambulatory  Support. — The 
most  severe  criticisms  of  the  jacket  have  been  made  by  those 
unfamiliar  with  its  use,  on  theoretical  grounds  rather  than  from 
actual  observation.  ^Miile  it  may  be  admitted  that  there  are 
certain  objections  to  the  support,  yet  experience  has  shown  that 
when  it  is  applied  in  a  proper  manner  under  proper  conditions  it 
is  a  thoroughly  reliable,  efficient,  and  often  indispensable  means 
of  treatment.  Indeed,  it  may  be  stated  that  by  means  of  the 
jacket  and  the  stretcher  frame  it  is  possible  to  treat  nearly  every 
case  of  Pott's  disease  without  the  aid  of  the  professional  brace- 
maker,  and  with  success. 

It  is  evident,  however,  that  under  certain  conditions  the  jacket 
must  be  inferior  to  the  brace,  in  early  childhood  for  example, 
when  the  pelvis  is  not  sufficiently  developed  for  proper  support. 
Again,  when  the  disease  is  low  down,  at  or  near  the  lumbosacral 
junction,  the  lower  border  of  the  jacket  does  not  hold  the  pelvis 
with  sufficient  security  to  provide  the  proper  fixation.  In  the 
upper  dorsal  region  the  attachments  for  accurate  fixation  may  be 
adjusted  more  readily  to  the  brace,  and  in  disease  of  the  cervical 
region  the  metallic  head  support  is  to  be  preferred  to  the  halter 
of  the  jury-mast,  for  the  reason  that  it  cannot  be  removed  by  the 
patient.  The  traction  of  the  jury-mast  is  very  effective  when 
properly  used,  and  particularly  so  when  painful  distortion  of  the 
neck  is  present,  h)ut  the  tension  on  the  straps  is  rarely  constant, 
and  thus  loses  in  efficiency.  A  rigid  support  is,  of  course,  prefer- 
able in  the  disease  of  the  atloaxoid  region. 

I'lie  jacket  is  most  serviceal:)le  in  the  region  from  the  tenth 
dorsal  to  the  second  lumbar  vertebra.  It  is  not  only  effective, 
but  it  is  often  a  mf)re  comfortable  support  than  the  spinal  brace. 
It  is  more  efficient  than  the  brace  when  lateral  deviation  of  the 
spine  is  present;  and  from  the  clinical  standpoint  it  is  often  more 
efficacious  in  relieving  pain  in  this  region  when  the  disease  is  at 
all  acute.  One  may  conclude,  then,  that  each  form  of  support 
may  be  userl  according  to  the  indications.  The  absolute  control 
of  the  treatment,  assured  by  the  use  of  the  plaster  jacket,  will 
often  overbalance  the  claims  of  the  brace.     In  practice  among  the 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


97 


poor,  when  choice  of  means  is  not  always  permitted,  it  is  indis- 
pensable; and  it  may  be  used  with  fair  success  even  under  con- 
ditions that  theoretically  contraindicate  its  employment. 

Modifications  of  the  Jacket. — Occasionally,  the  form  of  the 
jacket  may  be  changed  to  meet  special  indications;  for  example, 
backward  traction  may  be  secured  by  carrying  the  bandages  over 
the  shoulders;  or  the  head  may  be  fixed  in  the  support,  if  the 
jury-mast  is   not  at  hand  (Fig.  G4);  or  one  or  both  thighs  may 


Fig.  64 


Plaster    jacket,  including    the    head  to  hold  the  spine  in  the  extended  position, 
as  applied  for  disease  of  the  upper  dorsal  region. 

be  included  in  a  spica  jacket  in  painful  disease  of  the  lower  region, 
when  psoas  spasm  is  present.  Such  modifications  are  required 
rather  for  emergencies  than  for  continuous  treatment. 

Corsets  of  Other  Material  than  Plaster  of  Paris. — Corsets  of 
wood,  leather,  paper,  poroplastic  felt,  antl  celluloid  are  sometimes 
used.  These  are  constructed  on  a  plaster  cast  of  the  body,  an 
accurately  fitting  jacket  being  used  as  a  mould. 

T 


98  OB  THOPEDIC  S  UB  GER  Y 

Such  corsets  have  certain  advantages  of  durability  and  elegance, 
but  none  of  them  has  the  accuracy  of  fit  of  the  plaster-of-Paris 
corset,  which  is  moulded  directly  on  the  body.  Corsets  of  this  class 
are  usually  somewhat  expensive,  and  on  that  account  are  often  worn 
after  they  are  outgrown  or  when  they  no  longer  fit  the  patient. 
Their  use  is  practically  limited  to  the  stage  of  recovery  or  for  other 
affections  than  Pott's  disease. 

Of  these  corsets,  one  of  the  best  is  that  used  by  Weigel,  of 
Rochester,  made  of  alternate  layers  of  linen  cloth  and  wood-pulp 
matrix  paper,  fixed  by  a  mixture  of  paste  and  glue. 

A  more  durable  corset  may  be  constructed  of  aluminum,  as 
suggested  by  Phelps.  This  may  be  obtained  in  thin  sheets, 
which  may  be  hammered  upon  a  metal  cast  of  the  trunk  into  the 
proper  shape.  The  two  halves  are  attached  by  hinges  in  the 
back  and  are  perforated  to  permit  ventilation. 

In  the  final  stage  of  treatment,  the  Knight  brace,  a  light  steel 
frame  with  corset  front,  may  be  used  (Fig.  68)  or  a  long  corset 
similar  to  that  ordinarily  worn  by  women,  but  strengthened  by 
the  insertion  of  light  steel  bars  along  the  spine,  may  be  sufficient. 

Other  Forms  of  Support. — In  certain  cases  of  disease  of  the  lower 
lumbar  region  it  may^*advisable  to  restrain  the  movements  of 
the  thighs,  although  ordinarily,  when  this  is  necessary,  ambulation 
should  be  discontinued.  Such  restraint  may  be  attained  by 
making  the  back  bars  of  the  brace  stronger  and  extending  them 
down  the  thighs  to  the  knees  like  a  double  Thomas  hip  brace. 

If  the  jacket  is  used  it  may  be  extended  to  a  single  or  double 
spica  for  the  same  purpose  as  has  been  mentioned.  Such  appli- 
ances are  useful  when  psoas  spasm  and  "cramp"  are  troublesome 
symptoms. 

In  disease  of  the  cervical  region  a  certain  amount  of  support 
and  fixation  may  be  obtained  by  collars  of  poroplastic  felt,  plaster 
of  Paris,  or  other  material.  The  Thomas  collar  (Fig.  65  and  66) 
is  the  best  of  this  type  of  support,  but  none  of  them  is  thoroughly 
efficient  unless  used  with  a  brace  to  control  the  larger  movements 
of  the  spine.  They  are  useful  in  emergencies,  but  they  are  not 
often  required  when  proper  braces  can  be  obtained. 

Many  other  forms  of  apparatus  of  greater  or  less  merit  might 
be  described,  but  space  has  permitted  only  a  detailed  account  of 
three  forms  that,  it  would  seem  best,  represent  the  essential  prin- 
ciples  involved   in   the  treatment  of  Pott's   disease. 

The  Principles  of  Treatment  in  Their  Practical  Application. — After 
the  description   of  the  special  forms   of  apj)lianccs   used   in   the 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


99 


routine  treatment  of  Pott's  disease,  one  may  consider  with  ad- 
vantage the  treatment  in  its  more  direct  relation  to  the  patient. 
The  object  of  this  treatment  is  to  reheve  the  symptoms,  to  main- 
tain and  to  improve  the  vital  resistance  of  the  patient,  to  check, 
to  remedy,  and  to  prevent  deformity.  Under  favorable  con- 
ditions the  death-rate  is  small,  and  pain  is  easily  relieved,  but 
prevention  of  deformity  is  often  extremely  difficult. 

The  effect  of  treatment  must  be  estimated  not  simply  by  its 
relief  of  the  symptoms  of  the  disease,  since  deformity  may  steadily 
advance  in  spite  of  the  apparent  well-being  of  the  patient,  but  it 
must  be  selected  and  continued  or  changed  with  the  aim  of  com- 
bating ultimate  deformity,  and  on  this  standard  success  or  failure 
must  be  determined.     It  is  probable  that  noticeable  deformity 


Fig.  65 


The  Thomas  collar  of  leather  stuffed  with  cotton.     (Ridlon  and  Jones.) 
Fig.  66 


The  Thomas  collar  for  permanent  use.  A  piece  of  thin  sheet  metal  is  cut  wide 
enough  to  reach  from  the  sternum  to  the  chin,  and  from  the  back  of  the  neck  to  the 
base  of  the  occiput.  The  edges  are  turned  out  and  the  whole  properly  covered  with 
felt  and  fitted.     (Ridlon  and  Jones.) 


might  be  prevented,  nearly  always,  if  treatment  were  applied  in 
season.  But  practically  such  opportunity  is  not  often  offered, 
and  the  local  deformity  that  represents  destruction  of  bone  may 
be  considered  as  irremediable.  There  is  also  a  dwarfing  and 
blighting  effect  of  the  disease,  which,  although  it  is  usually  asso- 
ciated with  marked  deformity,  is  always  to  be  feared,  particularly 
when  the  disease  affects  the  middle  or  lower  region  of  the  spine 
in  early  childhood,  and  is  severe  and  prolonged  in  its  course. 
By  proper  treatment  one  may  hope  to  check  the  progress  of  the 


100 


ORTHOPEDIC  SURGERY 


disease  and  even  to  remedy  the  deformity  in  great  degree  by  free- 
ing the  spine  from  the  deforming  influence  of  the  local  process 
and  by  preventing  or  removing  the  symptomatic  distortions  such 
as  psoas  contraction  or  wryneck. 

Indications  for  Treatment  by  Recumbency. — As  has  been  stated 
already,  the  nwst  important  influence  toward  deformity  when  the 
spine  has  been  weakened  by  disease  is  the  force  of  gravity;  there- 
fore, horizontal  fixation  in  overextension  is  the  most  efficient 
means  of  preventmg  deformity,  and  of  assuring  the  rest  that 
favors  repair. 


Fig.  67 


The  Thomas  collar  applied.     (Ridlon  and  Jones.) 


This  is  always  the  treatment  for  emergencies  and  in  many 
instances  the  treatment  of  choice  and  routine.  It  is  indicated  as 
the  routine  treatment  in  infancy  and  in  early  childhood  up  to 
the  age  of  three  years   at  least. 

In  many  instances  absolute  recumbency  may  not  be  required, 
but  the  period  of  activity  must  be  carefully  regulated,  and  must 
be  discontinued  when  there  is  evidence  of  discomfort  or  weakness 
or  pain.  If  the  period  of  activity  must  be  short,  it  should  be 
passed  in  the  open  air.  The  passive  attitude  of  sitting,  although 
less  strain  is  thrown  upon  the  spine  than  during  activity,  may  be 
even  w(jrso  for  the  patient;  thus,  the  reclining  or  semi-reclining 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


101 


posture  should  be  assumed  as  a  rule,  when  the  child  is  in  the 
house,  at  least  during  the  active  stage  of  the  disease.  Even  if 
the  spine  appears  to  be  perfectly  supported,  the  time  spent  in 
bed  should  be  long,  and  a  period  of  rest  in  the  middle  of  the  day 
should  be  enforced. 

The  arguments  in  favor  of  horizontal  fixation  in  early  child- 
hood do  not  apply  to  disease  in  the  adult.  At  this  stage  the 
structure  of  the  spine  is  resistant,  and  deformity  is  little  to  be 
feared,  while  such  confinement  would  be  irksome  and  impracti- 
cable; thus,  local  support,  supervision,  and,  if  possible,  a  change 

Fig.  68 


The  Knight  brace  with  the  back  bars  prolonged  to  support  the  head. 

of  climate  must  be  the  treatment  of  selection  for  the  adolescent 
or   adult. 

In  the  middle  period  of  childhood,  from  the  fifth  to  the  tenth 
year,  horizontal  fixation  is  the  treatment  for  emergencies;  for 
paralysis,  for  abscess,  for  dangerous  disease  of  the  atlo-axoid 
region,  for  progressive  deformity,  and  for  pain  that  cannot  be 
relieved    by    the    ortlinary    means. 

Special  Indications  for  Treatment  of  Diseases  of  the  Differ- 
ent Regions  of  the  Spine. — In  the  selection  of  treatment,  and 
in  the  general  management  of  Pott's  disease,  each  region  of  the 


102 


ORTHOPEDIC  SURGERY 


spine  must  be  judged  by  itself,  since  in  each  there  are  special 
difficulties  to  be  met,  and  complications  to  be  feared  that  may 
influence  the  prognosis  and  lead  to  modifications  of  the  routine  of 
treatment. 

The  Lawer  Region. — The  prognosis  is  good  in  disease  of  the 
lower  region,  the  symptomatic  attitude  is  favorable,  the  part  may 
be  supported  easily,  the  cases  are  often  seen  early,  and  one 
may,  as  a  rule,  predict  recovery  without  noticeable  deformity, 
at  most,  but  a  slight  shortening  and  broadening  of  the  trunk 
and  a  peculiar  erectness  of  attitude.     Uncomplicated  cases  may 

Fig.  69 


Pott's  disease  of  the  middle  dorsal  region,  a  type  of  disease  in  which  horizontal 
fixation  is  always  indicated.     H.  S.,  aged  fourteen  months. 


be  treated  with  the  brace  or  jacket.  The  brace  is 
support  when  the  disease  is  near  the  sacrum,  while 
is  often  more  comfortable  and  more  effective  tliau 
when  the  middle  or  upper  luml)ar  region  is  disease 
larly  when  lateral  deviation  of  the  spine  is  present. 
the  tendency  to  psoas  contraction  is  at  all  marked  or 
or  cramjjs  in  tlie  liml)S  are  com{)lained  of,  the  period 
should  be  carefully  restricted;  in  fact,  the  "night  cry 
dication  for  a  day  of  rest  in  bed. 


the  better 
the  jacket 

the  brace 
d,  particu- 

Whenever 
when  pain 
of  activity 
"  is  an  in- 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


103 


The  most  troublesome  complications  of  this  region  are  psoas 
contraction  and  the  abscess  with  which  it  is  often  combined. 

As  has  been  stated,  psoas  contraction  changes  the  attitude 
of  overerectness,  favorable  to  repair,  to  a  forward  stoop  that 
increases  the  pressure  and  friction  at  the  seat  of  disease.  If 
this  attitude  persists  and  if  it  becomes  fixed  by  permanent  changes, 
such  as  are  likely  to  follow  the  burrowing  of  a  pelvic  abscess 
most  disastrous  deformity  may  follow;  the  body  and  the  thighs 
are  approximated  and  the  erect  attitude  is  made  impossible. 
In  neglected  cases  of  this  character,  tenotomy  and  forcible  cor- 
rection or  even  subtrochanteric  osteotomy  may  be  necessary  to 


Fig.  70 


H.  S.,  after  fixation  for  fourteen  months  on  the  modified    Bradford  frame, 
shows  the  recession  of  deformity.      Compare  with  Fig.  69. 

overcome  the  secondary  deformity.  In  ordinary  cases  of  psoas 
contraction,  and  when  one  limb  only  is  flexed,  the  patient  may 
be  allowed  to  go  about  using  a  high  shoe  on  the  imaffected  side, 
and  crutches,  so  that  the  flexed  leg  need  not  affect  the  attitude. 
If,  however,  the  contraction  persists,  it  is  well  to  place  the  patient 
on  a  frame,  and  to  reduce  the  flexion  by  traction  in  the  line  of 
deformity,  as  will  be  described  in  the  treatment  of  disease  of  the 
hip-joint.  Persistent  psoas  contraction  is  almost  always  a  symp- 
tom of  abscess  about  the  origin  or  in  the  substance  of  the  muscle, 
and  when  it  is  accompanied  by  pain  it  is  always  an  evidence  of 
progressive  disease. 
Abscess  may  be  expected  as  a  complication  in  at  least  50  per 


104 


ORTHOPEDIC  SUBGEUT 


cent,  of  the  cases  of  disease  of  this  region,  bnt  it  is  by  no  means 
always  accompanied  by  psoas  contraction,  any  more  than  psoas 
contraction  is  always  cansed  by  abscess.  Abscess  unaccompanied 
by  contraction  more  often  has  its  origin  above  the  lumbar  region, 
and  in  it&  descent  passes  along  the  surface  without  involving  the 
substance   of   the   muscle. 


Fig.  71 


Final  result  of  lumVjar  disease;  spontaneous  absorption  of  abscess,  and  but 
slight  deformity.     (.See  Fig.  13.) 

Attention  is  especially  called  to  the  fact  that  the  bad  results  of 
Pott's  disease  of  this  region  are  caused  almost  invariably  by 
allowing  psoas  contraction,  whether  it  be  symptomatic  of  abscess 
or  not,  to  persist;  therefore,  the  importance  of  preventing  and 
correcting  this  deformity  (tannot  be  overestimated.  It  should  be 
stated  however,  that  in  dispensary  practice,  when  special  care 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


105 


cannot  be  provided,  one  often  sees  psoas  contraction  that  may 
have  persisted  for  months  relax,  if  the  progress  of  the  disease  is 
favorable,  without  treatment  other  than  the  routine  fixation  of 
the  spine  by  the  brace  or  jacket  (Fig.  72), 

The  Lower  Dorsal  Region. — Disease  of  the  lower  dorsal  region 
is  very  favorably  situated  for  effective  mechanical  treatment,  and 
psoas  contraction  and  abscess  are  much  less  troublesome  than  in 
the  lower  part  of  the  spine. 

Fig.  72 


The  final  result  of  extreme  psoas  contraction      The  direct  bone  deformity  being 
comparatively   slight. 

Deformity  sometimes  increases,  almost  imperceptibly,  by  a 
progressive  forward  bending  or  lordosis  of  the  flexible  lumbar 
spine  below  the  projection.  One  must  guard  against  this  by 
applying  the  jacket  firmly  while  the  spiue  is  made  as  straight  as 
possible,  or,  if  the  brace  is  used,  the  lumbar  spine  should  be 
drawn  firmly  against  it. 


106  OBTHOPEDIC  SURGERY 

If  lateral  inclination  of  the  body  is  so  marked  as  to  interfere 
with  the  proper  application  of  a  brace,  preliminary  rest  in  bed  is 
indicated.  Lateral  de\'iation  can  be  corrected,  as  a  rule,  by  the 
jacket  without  recumbency,  although  this,  as  other  forms  of  symp- 
tomatic distortion,  should  be  treated  ordinarily,  if  not  by  com- 
plete rest,  at  least  by  careful  regulation  of  the  period  of  activity. 

Disease  of  the  Middle  and  Upper  Dorsal  Region. — This  is,  from 
the  standpoint  of  prevention  of  deformity,  the  most  difficult 
region  of  the  spine  to  treat,  although  the  symptoms  of  the  disease 
may  be  easily  relieved. 

Deformity  is  present  in  nearly  all  cases  when  treatment  is 
sought,  and,  deformity  having  begun,  is  very  difficult  to  check, 
for  the  reasons   that  have  been  stated  already. 

The  final  result  in  the  majority  of  cases  is  what  appears  to  be 
exaggerated  round  shoulders;  the  neck  is  shortened  and  projects 
forward,  the  chest  is  flat,  and  the  shoulders  are  high. 

It  is  only  by  an  early  diagnosis  and  by  efficient  and  long- 
continued  treatment,  beginning,  if  practicable,  with  horizontal 
fixation,  that  recovery  from  disease  in  this  region  without  notice- 
able deformity  may  be  hoped  for. 

In  all  cases  of  disease  above  the  ninth  vertebra,  the  anterior 
brace  for  backward  traction  of  the  shoulders  may  be  used  with 
great  advantage  to  secure  greater  fixation  of  the  spine;  and  in  all 
cases  above  the  seventh  or  eighth  vertebra  a  head  or  chin  support 
to  restrain  the  forward  inclination  of  the  neck  is  indicated  in 
addition. 

With  the  plaster  jacket  the  jury-mast  or  posterior  support  is 
employed;  with  the  brace  the  looped  chin  rest  or  the  ordinary 
Taylor  support  may  be  used. 

In  disease  of  the  upper  dorsal  region  the  brace  is  to  be  preferred 
to  the  jacket,  because  of  the  greater  accuracy  of  adjustment,  and 
because  the  halter  of  the  jury-mast  is  rarely  retained  in  proper 
position  when  the  patient  does  not,  as  in  these  cases,  feel  the 
need  of  such  support. 

In  this  region  of  the  spine  'paralysis  frequently  occurs  as  a  com- 
plication. When  it  appears  after  treatment  is  begun,  it  is  usually 
a  result  of  inefficient  fixation  of  the  spine  or  of  want  of  caution  in 
regulating  the  strain  to  which  the  diseased  part  is  subjected. 
Its  symptoms  anfl  its  treatment  will  be  considered  later. 

Disease  of  the  Upper  Dorsal  and  Middle  Cervical  Region. — This 
is  the  most  favorable  region  of  the  spine  for  treatment.  The 
disease  is  usually  not  extensive  because  of  the  small  size  and  com- 


TUBERCULOUS  DISEASE  OE  THE  SPINE  107 

pact  structure  of  the  vertebrae;  and  the  mobility  of  the  cervical 
region  is  so  great  that  it  readily  compensates  for  the  local  rigidity. 
Under  efficient  treatment  one  may  predict  recovery  without 
noticeable  deformity,  and  in  the  less  successful  cases  the  deform- 
ity is  not,  as  a  rule,  offensive.  The  shoulders  appear  high,  the 
neck  is  short,  the  head  inclines  forward,  while  the  back  is  abnor- 
mally flat  in  compensation  for  the  change  in  contour  of  the  part 
above. 

When  the  case  of  cervical  disease  is  first  brought  for  treatment 
a  wryneck  deformity,  often  made  more  persistent  by  the  infiltra- 
tion of  an  abscess  or  by  enlarged  cervical  glands,  is  almost  always 
present.  As  a  means  of  correcting  this  distortion,  the  jury-mast 
and  traction  halter,  attached  to  the  jacket  or  brace,  is  a  very 
efficient  and  comfortable  support.  Under  the  constant  tension 
the  deformity  may  be  corrected  with  ease,  but  as  a  permanent 
treatment  the  brace  and  head  support  are  to  be  preferred  to  the 
jury-mast,  because  a  more  exact  fixation  is  assured. 

Disease  of  the  Occipitoaxoid  Region. — Under  efficient  treatment 
the  -prognosis  is  good,  and  recovery  without  deformity  should  be 
the  rule.  The  course  of  the  disease,  although  it  is  often  accom- 
panied by  acute  symptoms,  is  usually  short,  as  compared  with 
that  of  other  regions  of  the  spine.  It  may  be  assumed  that,  in 
many  cases,  it  is  a  primary  arthritis,  or,  at  least,  that  the  primary 
focus  in  the  atlas  or  axis  is  very  small.  The  disease  at  this  point 
is,  however,  in  close  proximity  to  the  vital  centres,  and  sudden 
death  from  displacement  of  the  weakened  parts  is  not  uncommon. 
Abscess  is  frequent,  and  it  is  often  a  troublesome  and  dangerous 
complication. 

As  has  been  mentioned,  wryneck  deformity  is  a  very  constant 
symptom,  and  there  is  also  a  strong  tendency  toward  a  forward 
and  downward  inclination  of  the  head,  so  that  in  neglected  cases 
the  chin  may  rest  upon  the  chest.  The  mdications  for  treatment 
are  to  overcome  the  distortion  and  to  hold  the  head  fixed  in  the 
middle  line,  the  chin  being  somewhat  elevated  above  the  right- 
angled  relation  with  the  spine.  In  the  mild  cases  the  jacket  with 
jury-mast  traction  may  be  used  to  overcome  the  distortion,  but 
the  metallic  head  support  with  the  fixation  attachment  to  prevent 
motion  in  the  diseased  joints  is  always  indicated  as  the  treatment 
of  selection,  because  by  such  apparatus  the  danger  of  displacement 
may  be  avoided. 

When  the  disease  is  acute  in  character,  and  especially  if  abscess 
is  present,  recumbency  on  the  frame  with  fixation  of  the  head  and 


108  ORTHOPEDIC  SURGERY 

slight  traction  bv  the  weight  and  pulley,  or  by  the  jury-mast 
attachment,  is  indicated.  This  should  not  be  sufficient  to 
cause  discomfort.  Countertraction  is  supplied  by  the  weight  of 
the  bodv  and  by  elevation  of  the  head  of  the  bed  or  of  the  frame. 
The  head  sling  may  be  that  used  with  the  jury-mast,  or  a  simple 
band  about  the  head  may  be  used.  Under  this  treatment 
slight  deformity  of  any  part  of  the  cervical  region  will  prac- 
tically disappear,  and,  as  a  rule,  the  course  of  the  disease  is  very 
favorably  influenced  by  the  period  of  complete  rest.  In  certain 
cases  the  attitude  of  recumbency  is  extremely  uncomfortable. 
The  discomfort  is  caused  apparently  by  the  forward  projection  of 
the  upper  part  of  the  spme,  so  that  when  the  head  is  drawn  up- 
ward and  backward  in  the  recumbent  attitude  the  calibre  of  the 
throat  is  lessened.  In  other  instances  the  pain  may  be  due  to 
pressure  of  the  atlas  against  the  odontoid  process  of  the  axis.  In 
such  cases,  if  recumbency  is  desired,  the  head  must  be  elevated 
by  pillows  to  the  point  of  comfort,  the  support  being  removed 
when  the  child  has  become  accustomed  to  the  position,  or  when 
the  deformity  has  been  corrected. 

The  Complications  of  Pott's  Disease.  Abscess. — It  may  be 
assumed  that  a  limited  collection  of  tuberculous  fluid  is  present 
at  some  time  during  the  course  of  Pott's  disease  in  the  great 
majority  of  cases,  but  unless  it  appears  as  a  palpable  tumor  above 
or  below  the  thorax  or  upon  the  surface  of  the  body  its  presence 
is  not  often  detected. 

Townsend,^  in  380  cases  of  Pott's  disease  examined  with  refer- 
ence to  the  occurrence  of  abscess  as  a  complication,  found  that  it 
was  present  or  had  been  detected  in  75  (19.7  per  cent.);  in  8 
per  cent,  of  the  cases  of  cervical  disease;  in  20  per  cent,  of  the 
dorsal,  and  in  72  per  cent,  of  those  in  which  the  lumbar  region 
was  involved. 

Dollinger,''  in  700  cases  under  treatment  from  1883  to  1895, 
found  abscess  in  154  (22  per  cent,);  in  13  of  63  cases  in  the  cer- 
vical region  (22.6  per  cent.);  in  47  of  403  cases  in  the  thoracic 
region  (11.6  per  cent.),  and  in  94  of  234  cases  of  lumbar  disease 
(40.17   per  cent.). 

Ketch,^  in  75  cured  cases  of  Pott's  disease  treated  at  the  New 
York  Orthopedic  Dispensary,  selected  for  the  purpose  of  con- 
trasting the  behavior  of  the  disease  in  the  different  regions  of  the 
spine,  found  that  abscess  had  appeared  in  19  (25.3  per  cent.). 

>  Tranflactions  American  Orthopedic  Association,  vol.  iv.  p.  1G6. 

*  Loc.  cit. 

^  Transactions  American  Orthopedic  Absociation,  vol.  iv.  p.  200. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  109 

In  the  upper  region  abscess  was  detected  in  but  1  of  the  25  cases 
(4  per  cent.);  in  the  middle  region  in  8  of  the  25  cases  (32  per 
cent.),  and  in  the  lower  in  10  (40  per  cent.). 

In  354  autopsies  by  Mohr,  Nebel,  Bouvier,  and  T>annelongue 
abscess  was  found  in  281,  or  nearly  80  per  cent. 

Although  cases  of  Pott's  disease  that  come  to  autopsy  may  be 
supposed  to  represent  a  severe  type  of  disease,  yet  it  is  evident, 
by  contrasting  the  statistics,  that  a  large  proportion  of  the  ab- 
scesses escape  detection  in  the  living.  One  may  conclude,  then, 
that  abscess  may  be  expected  as  a  more  or  less  serious  complica- 
tion in  25  per  cent,  of  all  cases  of  Pott's  disease,  and  in  at  least 
half  of  those  in  which  the  lower  region  of  the  spine  is  affected. 
The  greater  frequency  here  is  explained  by  the  large  size  and 
less  resistant  structure  of  the  vertebral  bodies  as  compared  with 
those  of  the  upper  regions. 

The  tuberculous  abscess  is  separated  from  the  neighboring 
parts  by  a  limiting  wall  varying  in  thickness  according  to  its 
age,  the  outer  layers  of  which  are  of  fibrous  and  cellular  tissue, 
the  inner  of  granulation  tissue  covered  with  yellowish-gray  or 
pinkish-gray  necrotic  membrane,  which  is  easily  separated  from 
the  underlying  parts.  The  fluid  of  the  abscess  is  usually  of  a 
whitish  or  whey-like  color,  composed  of  serum,  leukocytes,  and 
emulsified  caseous  material  and  fibrin.  Floating  in  it  are  masses 
of  cheesy  necrotic  tissue  and  sometimes  minute  fragments  of  bone, 
which  settle  to  the  bottom  of  the  glass.  Certain  of  the  smaller 
quiescent  abscesses  contain  only  this  whitish  semisolid  material. 
The  fluid  of  abscesses  in  process  of  resolution  is  often  clear,  like 
serum;  but  if  secondary  infection  has  taken  place  the  pus  is  of  a 
greenish-yellow  color,  and  is  of  uniform  consistency.  At  any 
stage  of  its  progress  the  abscess  may  become  stationary  and  its 
contents  may  be  absorbed;  in  fact,  such  an  outcome  is  not  un- 
usual. The  fluid  of  the  abscess  is  usually  sterile,  and  secondary 
infection,  before  a  communication  with  the  exterior  of  the  body 
is  established,  is  comparatively  uncommon. 

It  has  been  claimed  that  abscess  formation  is  always  the  result 
of  infection  with  pyogenic  germs,  but  this  may  be  doubted,  since 
the  ordinary  tuberculous  abscess  may  be  sterile  or  at  most  contain 
but  a  few  tubercle  bacilli.  It  is  certain,  on  the  other  hand,  that 
the  formation  and  increase  of  the  abscess  is  favored  by  irritation 
and  injury,  and  that  the  most  eft'ective  treatment  of  this  compli- 
cation is  to  support  the  diseased  spine  and  to  relieve  it  from  over- 
strain. 


110  OR  THOPEDIC  S  UB  G  ER  Y 

x\bscess  is  a  s}-mptom  of  disease,  and  it  is  in  some  degree  an 
evidence  of  its  character.  If  it  appears  early  and  increases  in 
size  rapidly  it  usually  indicates  a  destructive  and  rapidly  advanc- 
ing process,  or  infection  from  without.  On  the  other  hand,  the 
slowly  enlarging  or  quiescent  abscess  has  but  little  significance. 
The  abscess  may  cause  no  symptoms  whatever,  or  it  may  be 
a  source  of  inconvenience  simply  because  of  its  size  or  situation. 
In  many  instances  however,  a  period  of  malaise  or  discomfort 
or  pain  is  followed  and  explained  by  the  appearance  of  an  abscess, 
but  whether  the  symptoms  are  caused  by  the  tension  of  the  ab- 
scess or  by  a  more  acute  phase  of  the  disease  itself  is  not  always 
clear. 

Large  abscesses  that  are  increasing  in  size  and  approaching  the 
surface  are  usually  accompanied  by  pain  and  by  elevation  of  tem- 
perature. This  indicates,  probably,  a  slight  degree  of  secondary 
infection,  but  the  ordinary  deep  abscess  appears  to  have  no  other 
effect  than  to  add,  doubtless,  to  the  susceptibility  of  the  patient. 

The  Course  and  Peculiarities  of  Abscess  in  the  Different  Regions 
of  the  Spine. — The  tuberculous  abscess  may  remain  as  a  small 
collection  of  fluid  in  the  neighborhood  of  the  diseased  area.  As 
a  rule,  however,  it  slowly  increases  in  size,  and  under  the  in- 
fluences of  the  force  of  gravity  and  the  tension  of  its  contents  it 
finds  its  way  down  the  spine  or  toward  the  exterior  of  the  body, 
following  the  path  of  least  resistance.  The  abscesses  that  have 
passed  below  the  diaphragm  or  that  have  originated  below  this 
point  may  follow  various  paths.  Some  enter  the  sheath  of  the 
psoas  muscle,  and  finally  make  their  appearance  on  the  inner 
aspect  of  the  thigh,  'psoas  abscess.  Others  perforate  the  sheath 
of  the  quadratus  lumborum  muscle  and  form  a  lumbar  abscess, 
projecting  between  the  twelfth  rib  and  the  crest  of  the  ilium  at 
the  triangle  of  Petit.  Those  abscesses  that  escape  from  the  fascia 
of  the  psoas  muscle  or  that  pass  downward  on  the  surface  of  the 
iliac  fascia,  the  so-called  iliac  abscesses,  may  appear  as  a  tumor 
over  the  outer  extremity  of  Poupart's  ligament  at  the  junction  of 
the  transversalis  and  iliac  fasciae,  or  the  fluid  may  follow  the 
course  of  the  iliac  artery  to  the  thigh,  or,  escaping  from  the  greater 
sacrosciatic  foramen,  form  a  (/luteal  abscess.  The  iliac  or  psoas 
abscess  is  most  often  confined  to  one  side,  but  it  may  be  bilateral, 
the  two  sacs  communicating  with  one  another  by  a  larger  or 
smaller  channel. 

In  the  thoracic  region  the  abscess  may  remain  indefinitely  in 
the  pf>steri(;r  mediastinum,  where,  if  large,  its  presence  may  be 


TUBERCULOUS  DISEASE  OF  THE  SPINE 


111 


demonstrated  by  an  area  of  dulness  extending  toward  the  lateral 
region  of  the  thorax,  or  it  may  perforate  the  intercostal  muscles 
and  appear  on  the  posterior  or  lateral  aspect  of  the  chest,  or  it 
may  pass  downward  through  the  aortic  opening  in  the  diaphragm 
and  become  an  iliac  abscess. 

Abscess  caused  by  disease  of  the  occi'pitoaxoid  region  may 
force  its  way  forward  between  the  recti  muscles  and  appear  be- 
hind the  pharynx  as  the  retropharyngeal  abscess,  or  the  fluid 
may   take   the   opposite   direction   and    distend    the   suboccipital 


Fig.  73 


Bilateral  lumbar  abscess 


triangle  and  then  pass  forward  to  the  region  of  the  mastoid  process. 
In  other  instances  the  abscess  may  dissect  its  way  about  the  base 
of  the  skull  or  pass  upward  through  the  foramen  magnum  or 
downward  into  the  spinal  canal. 

Abscesses  from  the  middle  cervical  region  usually  pass  outward 
between  the  scaleni  and  longus  colli  muscles  to  the  interval  be- 
tween the  trapezius  and  sternomastoid,  perforating  the  skin  about 
the  middle  of  the  lateral  aspect  of  the  neck  near  the  anterior 
border  of  the  latter  muscle. 


112  ORTHOPEDIC  SURGERY 

These  are  the  paths  usually  followed  by  the  tuberculous  fluid, 
but  occasionally  it  may  enter  the  spinal  canal  or  break  into  the 
pleural  cavity  or  lung  or  intestine  or  by  the  side  of  the  rectum  or 
elsewhere. 

Treatment  of  Abscess. — Abscess  is  by  far  the  most  troublesome 
and  dangerous  complication  of  Pott's  disease.  It  may  interfere 
with  proper  mechanical  treatment,  and  it  is  often  a  cause  of  per- 
manent as  well  as  temporary  deformity,  especially  in  the  lower 
region  of  the  spine,  as  has  been  stated.  It  prolongs  the  course 
of  the  disease  by  extending  its  boundaries,  and,  although  it  is 
not  often  a  direct  cause  of  death,  yet  many  patients  die  because 
of  the  exhaustion  of  long-continued  suppuration  that  may  follow 
secondary  infection,  and  of  the  amyloid  degeneration  that  may 
finally  result. 

A  large  abscess  is  always  a  source  of  danger  because  of  the 
possibility  of  secondary  infection  of  its  contents  before  it  finds 
an  outlet,  and  because  of  the  probability  of  infection  when  a  com- 
munication with  the  exterior  has  been  established.  Abscess  is, 
however,  a  symptom  and  result  of  disease,  and  in  properly  treated 
cases  it  is,  as  a  rule,  a  complication  of  comparatively  slight  con- 
sequence. If  it  is  not  present  when  treatment  is  begun,  one  may 
hope  to  prevent  it  by  effective  protection  of  the  spine;  and  if  it 
is  present,  this  protection  should  be  all  the  more  rigidly  enforced. 
An  abscess  often  exists  for  months  before  its  presence  is  detected, 
and  after  its  discovery  it  may  remain  quiescent  for  a  long  time, 
and  finally  disappear. 

In  a  large  proportion  of  cases  the  abscess  causes  no  symp- 
toms, but  slowly  finds  its  way  to  the  surface  of  the  body.  Mean- 
while it  may  be  assumed  that  the  disease  of  the  spine,  of  which 
the  abscess  is  a  result,  is  in  process  of  cure;  so  that  when  the 
fluid  finds  an  outlet  the  source  of  supply  will  be  shut  off,  and 
thus  the  patient  is  spared  the  danger  and  discomfort  of  discharg- 
ing sinuses,  that  so  often  persist  after  early  operation. 

The  so-called  radical  treatment  of  the  abscess  of  spinal  disease 
is  unsatisfactory,  not  because  it  is  different  in  character  from 
other  tuberculous  abscesses,  but  because  it  is,  as  a  rule,  impossible 
to  remove  the  disease  of  which  the  abscess  is  a  symptom;  and 
incomplete  or  ineffective  surgical  operations  should  be  avoided. 

As  the  abscess  is  a  symptom  of  disease,  so,  as  a  rule,  its 
treatment  should  be  symptomatic.  The  retropharyngeal  abscess 
demands  prompt  evacuation,  because  it  is  likely  to  obstruct 
breatliing  and  swallowing,  because  its  sudden  rupture  may  cause 


TUBERCULOUS  DISEASE  OF  THE  SPINE  113 

death,  and  because  an  abscess  in  such  close  proximity  to  the  vital 
centres  is  always  a  source  of  danger.  In  cases  of  emergency  the 
abscess  may  be  evacuated  by  an  incision  in  the  middle  line  of  the 
pharynx,  but  preferably  the  opening  should  be  from  the  exterior. 
An  incision  is  made  along  the  posterior  aspect  of  the  sterno- 
mastoid  muscle  in  its  upper  third.  The  abscess  tumor  is  easily 
reached  by  careful  dissection,  and  drainage  is  established  which 
has  evident  advantages  over  that  into  the  throat. 

Abscesses  from  the  middle  cervical  region  usually  point  in  the 
lateral  region  of  the  neck  and  cause  but  little  inconvenience. 
Abscesses  in  the  upper  thoracic  region  may,  in  rare  instances, 
cause  dangerous  pressure  on  the  trachea  or  lungs,  as  shown  by 
spasmodic  attacks  of  inspiratory  dyspnoea,  "asthmatic  attacks." 
In  some  instances  an  area  of  dulness  near  the  seat  of  disease 
demonstrates  the  position  of  the  abscess,  but  if  it  lies  in  the 
median  line  it  cannot  be  detected  either  by  auscultation  or  per- 
cussion. If  the  inspiratory  dyspnoea  is  well-marked  the  s}inptom 
may  be  fairly  attributed  to  this  cause,  and  if  the  spasmodic  attacks 
are  frequent  and  severe  the  operation  of  costotransversectomy  is 
indicated.  An  incision  is  made,  preferably  on  the  right  side, 
to  expose  the  articulation  between  the  transverse  process  and  the 
rib,  and  one  or  two  of  these  joints  is  resected;  the  finger  is  then 
inserted  and  passed  along  the  surface  of  the  adjacent  vertebral 
body  until  the  abscess  sac  is  reached.  This  is  usually  directly  in 
front  of  the  spine  at  or  about  the  fifth  dorsal  vertebra.  After 
incision  a  large  drainage  tube  should  be  inserted  (Fig.  9). 

In  the  lower  region  of  the  spine  intervention  may  be  indicated 
because  there  is  evidence  of  secondary  injection.  In  this  event  if 
the  abscess  distends  the  lumbar  region  or  forms  a  sac  on  either 
side  of  the  spine,  an  opening  in  the  loin  on  one  or  both  sides  of 
the  spine  is  necessary.  This  is  made  as  in  operations  on  the 
kidney,  by  an  incision  on  the  outer  side  of  the  erector  spime 
muscle  between  the  last  rib  and  the  crest  of  the  ilium.  In  certain 
cases  it  is  possible  to  expose  the  spine  and  to  remove  fragments 
of  necrosed  bone  along  with  the  contents  of  the  abscess.  As  a 
rule,  the  complete  removal  of  the  lining  membrane  of  the  abscess 
is  not  practicable,  and  one  must  be  content  to  evacuate  the  solid 
and  semisolid  contents  by  flushing  with  hot  water,  together 
with  as  much  of  the  abscess  membrane  as  may  be  removed  by 
swabbing  with  gauze.  The  most  important  point  in  the  oper- 
ation is  to  provide  efficient  and  complete  drainage  of  the  cavity. 
Two  or  more  counteropenings   are  usually  necessary  when   the 

8 


314  ORTHOPEDIC  SURGERY 

lumbarjncision  has  been  made,  one  just  in  front  of  the  anterior 
superior  spine  and  another  in  the  thigh,  if  the  abscess  is  of  the 
psoas  variety.  Long  drainage  tubes  are  inserted,  and  should 
remain  until  a  proper  channel  for  the  escape  of  pus  has  been 
established. 

If  the  abscess  is  of  one  side  only,  not  extending  into  the  thigh, 
and  if  evacuation  seems  advisable  because  of  its  size  or  tension, 
it  may  be  opened  by  an  anterior  incision  below  Poupart's  ligament 
just  to  the  inner  side  of  the  sartorius  muscle.  After  expression 
of  its  contents  a  drainage  tube  may  be  inserted  long  enough 
to  reach  to  the  seat  of  disease  if  it  be  of  the  lumbar  region. 

The  dressing  should  be  of  dry  sterile  gauze,  and  great  attention 
should  be  paid  to  absolute  cleanliness  and  to  effective  drainage. 
As  soon  as  it  is  possible,  if  the  discharge  has  become  slight  and 
if  the  spine  can  be  properly  supported,  the  patient  is  allowed  to 
walk  about  and  to  go  into  the  open  air.  In  ordinary  cases  a  slight 
discharge  persists  for  several  months  or  longer,  depending  on  the 
condition  of  the  disease. 

In  the  symptomatic  treatment  of  abscess,  aspiration  is  some- 
times of  service,  for  by  this  means  it  may  be  prevented  from 
increasing  in  size;  and  if  the  disease  is  quiescent,  the  cure  of  the 
abscess  may  follow  the  removal  of  its  contents  which  allows  the 
collapse  of  its  walls.  When  aspiration  is  employed  it  should  be 
repeated  systematically  as  often  as  the  abscess  cavity  refills. 
After  each  evacuation  pressure  should  be  applied  to  favor  the 
adhesion  of  the  apposed  walls. 

If  the  contents  are  of  such  a  nature  that  aspiration  is  ineffec- 
tive an  incision  may  be  made,  through  which  the  semisolid  sub- 
stance may  be  removed.  The  opening  is  then  closed  by  several 
layers  of  sutures,  and  pressure  is  applied  with  the  aim  of  ob- 
taining primary  union.  This  operation  may  be  repeated  several 
times  if  necessary.  Often  a  sinus  eventually  forms  at  one  or  other 
of  the  openings. 

Until  recently  the  injection  of  antituberculous  remedies  into  the 
abscess  sac  was  in  favor.  This  is  probably  of  value  in  dimin- 
ishing the  infective  quality  of  the  contents,  perhaps,  also,  in 
lessening  the  danger  of  mixed  infection  and  in  stimulating  the 
reparative  processes.  Clinically,  it  appears  to  have  little  direct 
effect  upon  the  course  of  the  tuberculous  disease.  An  emulsion 
of  iodoform  in  sterilized  oil  or  glycerin  (10  to  20  per  cent.),  in 
doses  of  from  4  to  30  grams,  is  injected  at  intervals  of  from 
two  to  four  weeks,    with  or  without  previous  evacuation  of  the 


TVBERCULOUS  DISEASE   OF  THE  SPINE  II5 

contents;  the  amount  and  the  frequency  of  the  injection  depend- 
ing upon  the  age  of  the  patient  and  upon  the  effect  of  the  treat- 
ment. If  used  with  caution  as  to  asepsis,  and  to  the  toleration  of 
the  patient  for  iodoform,  no  harm  will  follow,  even  if  the  treat- 
ment proves  to  be  of  little  practical  value. 

When  an  abscess  approaches  the  surface  the  skin  becomes  red 
and  thin,  and  there  is  usually  some  local  sensitiveness  and  pain. 
Whenever  spontaneous  evacuation  of  the  abscess  is  probable  the 
mother  should  be  instructed  as  to  the  necessity  of  absolute  clean- 
liness, and  the  proper  dressings  should  be  provided.  In  such  an 
event  the  patient  should  remain  in  bed  for  several  days,  or  until 
the  discharge  has  become  small  in  amount. 

In  the  symptomatic  treatment  of  the  abscesses  of  Pott's  disease 
one  may  conclude,  then,  that  operation  will  be  indicated  in  the 
treatment  of  the  retropharyngeal  abscess  and  in  the  rare  instances 
when  dangerous  pressure  is  exerted  by  an  abscess  in  the  posterior 
mediastinum.  It  is  indicated,  of  course,  when  there  is  e\adence 
of  mixed  infection  or  when  the  rapidly  enlarging  abscess  causes 
discomfort  or  interferes  with  effective  support.  It  is  usually 
indicated  when  the  abscess  is  of  large  size  if  proper  care  can  be 
provided.  The  operative  treatment  is  practically  free  from 
danger  if  cleanliness  and  efficient  drainage  can  be  assured.  As- 
piration is  free  from  danger;  it  is  often  of  service  in  preventing 
the  enlargement  of  the  abscess,  and  it  may  hasten  its  absorp- 
tion. An  incision  which  allows  for  the  evacuation  of  the  solid 
material,  followed  by  immediate  closure  of  the  wound,  is  in  many 
instances  the  operation  of  selection. 


Paralysis.    "  Pott's  Paraplegia." 

The  tuberculous  process  in  the  vertebral  bodies  may  extend 
backward,  and  breaking  through  the  posterior  ligament  it  may 
enter  the  epidural  space  and  press  upon  the  spinal  cord;  then 
follows  paresis  or  paralysis  of  the  parts  below  the  constriction. 

The  calibre  of  the  spinal  canal  is  not  usually  lessened  bv  the 
characteristic  angular  distortion  of  the  spine,  although  the  wei<Tht 
and  forward  inclination  of  the  trunk  may  force  the  softened 
tissues  backward  against  the  cord  and  thus  increase  the  direct 
pressure;  in  fact,  paralysis  is  much  more  often  asscx-iated  with 
a  slight  or  moderate  kyphosis  than  with  extreme  deformity. 

In  rare  instances  the  pressure  may  be  due  to  a  fragment  of 


116  ORTHOPEDIC  SURGERY 

necrosed  bone  or  to  solidification  of  the  tissues  in  and  about  the 
canal  during  the  process  of  repair.  It  may  be  caused,  in  part, 
at  least,  by  the  pressure  of  a  neighboring  abscess,  but  it  is  usually 
the  result  of  the  slow  advance  of  the  tuberculous  disease.  When 
this  has  forced  an  entrance  into  the  spinal  canal  it  sets  up  a 
resistant  inflammatory  thickening  of  the  coverings  of  the  cord, 
— first  a  peripach^ineningitis  and  then  a  pachymeningitis.  In 
addition  to  the  direct  pressure,  there  may  be  an  interference 
with  blood  supply  and  the  Ijanphatic  circulation,  with  result- 
ing local  oedema  of  the  cord.  An  increase  in  the  interstitial 
connective  tissue  of  its  substance  and  a  corresponding  atrophy 
of  the  nervous  elements  may  follow,  and  as  a  sequence  an  ascend- 
ing and  descending  degeneration  that,  in  prolonged  cases,  may 
terminate  in  partial  or  complete  sclerosis.  The  dura  mater  is 
a  resistant  structure,  and  direct  destruction  of  the  cord  by  the 
tuberculous  disease  is  rare.  In  fact,  as  a  rule,  but  little  per- 
manent damage  results,  even  from  long-continued  pressure  and 
paralysis,  for  the  cord  seems  in  these  cases  to  possess  the  power 
of  repair  and  regeneration  to  a  remarkable  degree. 

Frequency. — In  1670  cases  of  Pott's  disease  recorded  at  the 
New  York  Orthopedic  Dispensary,  paralysis  occurred  in  218,*  and 
in  445  cases  in  the  private  practice  of  Dr.  C.  F.  Taylor,^  59  cases 
of  paralysis  were  observed.  Thus,  in  a  total  of  2015  cases  of 
Pott's  disease  there  were  279  cases  of  paralysis,  or  13.7  per  cent. 

This  proportion  is  much  larger  than  the  normal,  however,  for 
many  of  the  patients  were  taken  to  the  specialist  or  to  the  special 
hospital  because  of  the  paralysis,  as  in  40  of  Taylor's  and  in  133 
of  the  dispensary  cases.  If  these  be  excluded,  the  percentage  of 
paralysis  occurring  in  those  actually  under  treatment  is  reduced 
to  5.6  per  cent.  This  percentage  corresponds  very  closely  to 
that  of  Dollinger,^  viz.,  41  cases  of  paralysis  in  700  cases  of  Pott's 
disease  under  treatment  (5.8  per  cent.),  and  it  may  be  accepted 
as  representing  the  average  liability  to  paralysis  among  those 
who  have  received  treatment  for  Pott's  disease,  the  percentage 
being  much  higher  in  neglected  cases. 

The  Liability  to  Paralysis  in  Disease  of  the  Different  Regions  of 
the  Spine. — 'I'lie  liability  to  paralysis  is  very  much  greater  in 
disease  of  certain  regions  of  the  spine  than  in  others. 

Thus,  105  of  the  209  cases  in  Myers'  list,  in  which  the  situa- 

'  MyerB,  Transactionfl  American  Orthopedic  AspofiiaUon,  1K91,  vol.   iii.  p.  209. 

*  Taylor  and  Lovett,  Now  York  Medical  Record,  June  19,  1890. 

*  Loo.  cit. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  117 

tion  of  the  disease  was  recorded,  complicated  disease  of  the  dorsal 
region  above  the  eighth  vertebra.  Of  the  remainder,  in  16  the 
disease  was  of  the  cervical  region;  in  12  of  the  cervicodorsal,  and 
in  59  of  the  lower  dorsal  and  dorsolumbar  regions. 

Thirty-seven  of  Taylor's  59  cases  were  caused  by  disease  of  the 
dorsal  region;  8  occurred  in  the  cervical  and  cervicodorsal  and 
11  in  the  dorsolumbar  and  lumbar  regions. 

Twenty-six  of  the  total  of  41  cases  recorded  by  Dollinger  were 
caused  by  disease  of  the  third  to  the  seventh  dorsal  vertebrte, 
inclusive,  or  about  23  per  cent,  of  the  cases  in  which  this  region 
was   involved. 

Of  132  cases  of  paraplegia  reported  by  Gibney^  not  one  com- 
plicated lumbar  disease;  nearly  all  were  caused  by  compression 
in  the  middle  or  upper  thoracic  region. 

These  statistics  show  that  the  upper  and  middle  dorsal  section 
is  the  point  of  greatest  liability  to  paralysis — a  fact  that  is  ex- 
plained possibly  by  the  smaller  size  of  the  canal  at  this  point, 
and  by  the  difficulty  in  assuring  complete  fixation  at  the  seat  of 
disease.  It  may  be  estimated  that  in  15  per  cent,  of  the  cases 
of  Pott's  disease  of  this  region  paralysis  will  appear  before  cure 
is   established. 

Time  of  Onset. — In  exceptional  cases  the  paralysis  may  pre- 
cede deformity,  and  it  may  be  the  first  symptom  that  attracts 
attention  to  the  disease.  In  14  of  74  cases  reported  by  Gibney 
the  paralysis  was  present  when  the  bone  disease  was  recognized, 
but  it  is  probable  that  the  primary  disease  had  existed  for  several 
months  before  the  appearance  of  the  paralysis.  Usually  it  is 
a  comparatively  late  symptom,  appearing  after  the  stage  of 
deformity  and  more  often  six  to  twelve  months  after  the  recogni- 
tion of  the  disease,  but  its  appearance  may  be  deferred  until 
long  after  apparent  cure. 

Duration. — In  exceptional  cases  the  paralysis  appears  to  be 
caused  simply  by  disturbance  of  the  circulation  of  the  cord,  due 
possibly  to  the  pressure  of  the  superincumbent  weight  upon  the 
softened  and  diseased  tissues,  as  it  disappears  almost  immediately 
when  the  spine  is  straightened  and  supported.  Usually  the 
paralysis'  persists  for  several  months,  not  infrequently  it  lasts  a 
year,  and  partial  or  even  complete  recovery  is  possible  after  a 
much  longer  time.  Recovery  from  the  paralysis  depends  upon 
the  course  of  the  disease  of  which  it  is  a  sATiiptom,  upon  the  ab- 

'  Journal  of  Nervous  and  Mental  Disease,  January  5,  1897. 


118  ORTHOPEDIC  SURGERY 

sorption  and  organization  of  the  tuberculous  granulations  that 
press  upon  the  cord,  and  upon  the  regenerative  changes  in  its 
structure,  if  it  has  been  implicated  in  the  disease. 

Symptoms  of  Pott's  Paraplegia. — The  most  marked  effect  of 
the  pressure  on  the  cord  is  the  interference  with  its  conductivity. 
The  reflex  centres  situated  below  the  point  of  constriction,  re- 
lieved from  the  inhibition  of  the  brain,  become  overactive,  while 
voliuitary  motion  of  the  parts  below  the  constriction  is  difficult 
or  impossible.  The  pressure  of  the  diseased  products  is  more 
directly  upon  the  anterolateral  columns,  so  that  motion  is  much 
more  often  primarily  affected  than  is  sensation. 

The  early  sjauptoms  of  Pott's  paraplegia,  as  noticed  by  the 
patient  or  his  friends,  are  weakness,  awkwardness,  and  a  stum- 
bling, shambling  gait.     The    symptoms    usually  increase  rapidly 

Fig.  74 


Pott's  paraplegia  before  the  stage  of  deformity.     The  apparatus  used  in  the 
treatment  of  this  case  is  shown  in  Fig.  54 

until  paralysis  of  motion  is  complete.  At  this  stage  the  patella 
tendon  reflex  is  increased,  and  ankle-clonus  is  often  present.  As 
a  rule,  both  limbs  are  affected  in  equal  degree,  but  occasionally 
paralysis  of  one  may  be  more  complete  or  may  precede  that  of  the 
other,  and  in  the  stage  of  recovery  power  may  return  more  rapidly 
on  one  side  than  on  the  other.  The  limbs  in  the  early  stage  of  the 
paralysis  may  appear  limp  and  powerless,  but  when  the  patient 
is  moved  or  when  the  reflexes  are  stimulated  the  peculiar  spastic 
rigidity  or  stiffness  appears. 

As  a  rule,  the  stift'ness  increases  with  the  duration  of  the  dis- 
ease, and  spastic  contractions  are  often  present;  thus,  the  thighs 
may  be  approximated,  the  knees  flexed,  and  the  feet  extended. 
Persistent  contractions  intlicate,  as  a  rule,  permanent  damage  to 
the  cord,  and  in  such  cases  complete  recovery  is  unusual. 


TUBERCULOUS  DISEASE   OF  THE  SPINE  HQ 

Sensation  is  not  affected  ordinarily,  but  in  the  more  severe  or 
prolonged  cases  it  may  be  impaired  or  lost.  Sensation  was  re- 
tained throughout  in  24  of  the  40  cases  reported  by  Shaffer. 

In  the  cases  of  partial  paralysis  control  of  the  bladder  may  be 
retained,  but  usually  there  is  incontinence.  As  the  bladder  fills 
the  reflex  centre  is  excited,  and  it  empties  itself. 

The  control  of  the  sphincter  ani  is  less  often  or  less  noticeably 
affected. 

As  the  paralysis  is  the  result  in  many  instances  of  active  or  of 
advancing  disease  its  onset  may  be  preceded  by  discomfort  or 
pain.  Thus,  noticeable  discomfort  attended  by  an  exaggeration 
of  the  patella  tendon  reflex  may  be  considered  as  an  indication 
for  enforced  rest  of  the  individual,  although  increased  activity  of 
the  reflexes  is  rot  uncommon  during  the  progressive  stage  of  the 
disease  without  apparent  involvement  of  the  spinal  cord.  When 
paralysis  occurs  in  patients  who  are  under  treatment  for  Pott's 
disease  the  onset  is  not  attended,  as  a  rule,  by  noticeable  or  un- 
usual pain;  nor  is  pain  usually  complained  of  after  the  paralysis 
has   developed. 

The  extent  of  the  paralysis  depends  upon  the  situation  of  the 
disease.  In  exceptional  cases,  in  which  the  cervical  cord  is  im- 
plicated, both  the  arms  and  legs  may  be  paralyzed;  this 
occurred  in  seven  of  the  cases  reported  by  Myers.  As  a  rule,  how- 
ever, the  paralysis  is  a  complication  of  disease  of  the  dorsal  region 
above  the  reflex  centres  in  the  liunbar  enlargement  of  the  cord 
but  below  the  nerve  supply  of  the  upper  extremities.  If  the 
disease  is  at  a  lower  point,  for  example,  in  the  dorsolumbar  section 
so  that  these  reflex  centres  themselves  are  directly  implicated, 
reflex  activity  is  not  increased,  and  intermittent  incontinence 
is  replaced  by  constant  dribbling  of  urine.  If  the  cauda  equina 
alone  is  implicated  in  disease  of  the  lumbosacral  region  the 
symptoms  are  those  of  neuritis,  pain,  numbness,  and  weakness 
in  the  area  supplied  by  the  affected  nerves.  Such  weakness 
with  accompanying  muscular  atrophy  may  be  present  in  the  upper 
extremities  when  the  disease  is  in  the  neighborhood  of  the  origin 
of  the  brachial  plexus,  while  in  the  lower  limbs  the  characteristic 
spastic  condition  is  evident. 

In  characteristic  cases  the  nutrition  of  the  limbs  is  not,  as  a 
rule,  greatly  affected,  nor  do  the  contractions  become  permanent; 
but  when  the  paralysis  is  prolonged,  and  when  sensation  is  lost, 
the  muscles  waste,  the  circulation  is  impairetl,  and  fixed  distor- 
tions usually  appear.     Even  in  the  more  prolonged  and  severe 


120  ORTHOPEDIC  SUBOERY 

forms  of  paralysis,  occurring  in  childhood,  bed-sores  are  rarely 
seen. 

Progfnosis. — In  properly  treated  cases  the  prognosis  is  very 
favorable,  as  is  illustrated  by  the  final  results  of  47  of  the  59  cases 
of  paraplegia  in  Taylor's  practice.  Of  these  39  recovered  com- 
pletely, 5  died  of  intercurrent  disease  while  apparently  recov- 
ering, and  in  3  the  recovery  was  partial. 

Of  the  hospital  cases  recorded  by  Myers,  3  per  cent,  died  of 
intercurrent  disease.  The  final  results  could  be  ascertained  in 
but  55  per  cent,  of  the  patients  who  remained  under  treatment. 
All  of  these  recovered. 

Of  74  cases  of  paraplegia  treated  by  Gibney,^  45  were  cured, 
12  improved,  8  unimproved,  and  9  died.  Thus,  77  per  cent,  were 
cured  or  improved.  In  a  similar  series  of  40  cases  reported  by 
Shaffer,  SO  per  cent,  were  cured  and  but  10  per  cent,  of  the 
remainder  were  considered  as  hopeless  cases. 

In  a  total  of  975  cases  "abandoned  to  medical  treatment," 
collected  from  various  sources  by  Rozoy,"  there  were  429  cures. 
Of  the  remainder  16  were  improved,  130  were  unimproved,  and 
there  were  244  deaths.  The  contrast  in  the  results  reported  would 
appear  to  show  the  advantage  of  thorough  mechanical  treat- 
ment. 

Recurrence  of  paralysis  after  recovery  is  not  infrequent;  in 
18  cases  such  recurrences  from  one  to  four  times  are  recorded  by 
Myers,  and  seven  successive  attacks  of  paralysis  Were  observed 
in  a  patient  under  treatment  at  the  Hospital  for  Ruptured  and 
Crippled. 

The  relapses  are  due  apparently  to  the  renewed  activity  of 
the  disease,  and  in  many  instances  this  may  be  explained  by  the 
neglect  of  protective  treatment. 

Treatment. — The  treatment  of  the  paralysis  is  included  in  the 
treatment  of  the  disease  of  which  it  is  a  symptom,  except  that  even 
greater  care  should  be  exercised  to  assure  fixation  of  the  spine. 

Rest  in  the  position  of  hyperextension  on  the  stretcher  frame 
is  indicated.  Direct  traction  by  the  weight  and  pulley  should 
be  used  if  the  disease  is  in  the  upper  dorsal  or  cervical  regions. 
For  bedridden  patients  a  convenient  method  of  assuring  extension 
of  the  spine  in  connection  with  head  traction  is  to  suspend  the 
trunk  on  a  sling  of  canvas  drawn  transversely  beneath  the  seat 
of  disease  and  attached  to  bars  on  the  sides  of  the  bed  after  the 

'  Lee.  cit.  «  Mai.  do  Pott.  Pariw,  1901. 


TUBERCULOUS  DISEASE  OF  THE  SPINE  ]21 

Rauchfuss  method.  The  back  brace  or  the  plaster  jacket  assures 
additional  fixation,  and  such  support  should  be  employed  when- 
ever practicable.  If,  however,  the  brace  has  been  worn  as  an 
ambulatory  support,  its  shape  must  be  modified  to  accommodate 
the  change  in  the  outline  of  the  spine,  induced  by  recumbency 
and  extension. 

Manipulation  or  massage  of  the  limbs  is  contraindicated  because 
it  stimulates  the  reflex  centres.  If  persistent  contractions  of  the 
muscles  are  present  the  deformity  may  be  reduced  by  traction 
applied  in  the  ordinary  manner  (Fig.  33),  or  a  fixation  brace  may 
be  worn.  The  spasmodic  contractions  are  often  painful,  and  if 
the  paralysis  is  complicated  by  tuberculous  joint  disease,  traction 
and  fixation  may  be  indicated  to  relieve  the  joint  from  the  in- 
jury of  involuntary  motion. 

Counterirritation  at  the  seat  of  disease  was  by  Pott  considered 
of  the  greatest  value,  and  the  application  of  the  actual  cautery 
from  time  to  time,  about  the  kyphosis,  seems  in  certain  cases  to 
exert  a  favorable  influence  on  the  underlying  disease. 

Electricity,  particularly  galvanism,  has  been  used,  and  it  is  of 
some  service  in  preserving  the  nutrition  of  the  limbs.  Its  value 
in  a  case  must  be  judged  by  its  efl^ect. 

Internal  remedies  are  of  little  value  with  the  possible  exception  of 
iodide  of  potassium,  which  is  supposed  to  act  upon  the  tubercu- 
lous granulation. tissue  as  upon  the  products  of  syphilitic  disease. 
A  convenient  method  of  administration  is  a  solution  of  which  one 
drop  represents  one  grain  of  the  drug.  This  is  given  in  milk  or 
in  Vichy  water,  beginning  with  five  drops  three  times  daily  and 
increasing  the  dose  a  drop  each  day  until  the  point  of  toleration 
is  reached. 

The  first  indication  of  improvement  is  usually  lessening  of  the 
muscular  rigidity;  then  the  ability  to  move  a  toe  may  be  regained, 
after  which  recovery  follows  quickly.  At  this  stage  massage  of 
the  limbs  may  be  employed  with  advantage.  The  exaggerated 
reflexes  may  persist  long  after  recovery;  in  fact,  as  has  been  stated 
this  symptom  is  not  inicommon  among  patients  suffering  from 
dorsal  Pott's  disease  who  have  never  been  paralyzed. 

The  Operative  Treatment. — The  operation  of  laminectomy  was  at 
one  time  in  favor,  but  it  has  now  been  practically  abandoned,  as 
a  treatment  of  routine  at  least,  for  the  paraplegia  of  Pott's  disease, 
because  it  has  })een  proved  that  recovery,  if  somewhat  long  de- 
ferred, is  the  rule  without  operation,  while  the  direct  tleath-rate 
of  the  operation  is  large. 


122  ORTHOPEDIC  SURGERY 

In  134  cases  collected  by  Rhein^  the  immediate  mortality  (those 
d^nng  within  a  month  after  the  operation)  was  36  per  cent. 

Lloyd'  has  collected  128  "reliable"  cases  of  Pott's  disease  in 
which  laminectomy  was  performed.  The  deaths  due  directly  to 
the  operation  were  21  (16.45  per  cent.);  subsequent  deaths,  36 
(28.20  per  cent.);  total  deaths,  57  (44.55  per  cent.);  recoveries, 
37  (28  per  cent.);  improved,  16  (12.5  per  cent.);  unimproved, 
18  (14.06  per  cent.).  Of  eight  cases  operated  by  Trendelenburg 
in  1889  six  were  living  and  well  in  1905.     One  was  unimproved.^ 

Laminectomy  is  an  incomplete  operation  in  the  sense  that  the 
disease  of  the  bone  is  not  removed,  thus  recurrence  of  paralysis 
from  extension  of  the  disease  is  not  infrequent  after  a  successful 
immediate  result.  It  should  be  reserved  for  those  cases  in  which 
after  a  thorough  and  prolonged  trial  of  ordinary  methods  the  con- 
dition does  not  improve.  Eighteen  months  has  been  suggested 
as  the  proper  time  in  which  to  test  conservative  treatment.  The 
operation  may  be  indicated  also  if  the  symptoms,  in  spite  of  treat- 
ment, increase  in  severity,  particularly  when  the  cervical  region 
is  involved  or  when  there  is  evidence  that  the  integrity  of  the 
cord  is  threatened,  or  when  the  paralysis  is  of  sudden  onset,  or 
when  displacement  of  bone  or  pressure  from  an  abscess  seems 
probable  as  the  exciting  cause,  although  in  the  latter  instance 
the  direct  evacuation  of  the  abscess  by  costotransversectomy,  as 
advocated  by  Menard,  should  precede  laminectomy.  Occasion- 
ally, the  operation  is  indicated  as  a  forlorn  hope  in  adults  suffer- 
ing from  cystitis  and  bed-sores. 

The  usual  method  in  operating  is  as  follows:''  A  long  incision 
is  made  parallel  to  and  close  by  the  side  of  the  spinous  processes. 
The  muscles  are  drawn  to  one  side,  the  spinous  processes  are  cut 
through  and  drawn  with  the  attached  muscles  to  the  opposite 
side.  The  laminai  at  the  seat  of  disease  are  then  removed  with 
the  cutting  forceps  exposing  the  dura  mater.  The  tuberculous 
tissue  is  usually  found  upon  the  front  or  lateral  surfaces  of  the 
canal,  and  its  complete  removal  is  often  impossible.  The  shock 
of  the  operation  is  often  marked,  so  that  it  should  be  as  rapid  as 
possible,  and  loss  of  blood  sliould  be  carefully  guarded  against. 

'  Willard,  Journal  of  NervouH  and  Mental  Disease,  May,  1897. 

'■'  Philadelphia  Medical  Journal,  Feljruary  22,  1902. 

"  Sultan,  Zeitsch.  f.  Chir.  v.  Ixxviii.,  1  and  2. 

*  It  should  ho  borne  in  mind  that  the  segments  of  the  cord  do  not  correspond  to  the 
8pinou8  procesHOH  of  the  same  number.  Thus,  in  the  cervical  region  the  affected  seg- 
ment is  one  vertebra  higher.  In  the  upper  dorsal  region  two  higher.  From  the  sixth 
to  eleventh  dorsal  three  higher.  The  three  lower  lumbar  and  sacral  segments  are  to  I)© 
found  opposite  the  eleventh  t^nd  twelfth  d'Tsal  spines.     (Chipault.) 


TUBERCULOUS  DISEASE  OF  THE  SPJNE  123 

As  a  rule,  the  wound  may  be  closed  without  drainage.  After  the 
operation  the  spine  should  be  supported  by  the  brace  or  jacket 
until  the  disease  is  cured. 

In  several  instances  forcible  correction  of  the  spine  (Calot's 
operation)  relieved  the  pressure  on  the  cord  and  rapid  recovery 
followed.  This  indicates  the  importance  of  assuring  overexten- 
sion of  [the  spine  whenever  it  is  possible,  but  this  should  be 
attained  preferably  by  gradual,  postural  correction  rather  than 
by  force. 

Fortunately,  the  great  majority  of  cases  of  paraplegia  from 
Pott's  disease  occur  in  childhood,  and,  as  has  been  mentioned, 
the  complications  of  later  life,  bed-sores,  cystitis,  and  the  like,  are 
rarely  troublesome.  Such  paralysis  in  the  adult  is  more  serious 
from  every  point  of  view.  The  principles  of  treatment  are  the 
same,  but  their  application  is  more  difficult  and  the  prognosis  is 
more  doubtful. 

Local  Paralysis. — In  certain  cases  the  extension  of  the  disease 
may  involve  the  nerve  roots  at  their  exit  from  the  spine.  This 
may  occur  with  or  independently  of  the  involvement  of  the  cord. 
The  symptoms  are  those  of  neuritis  in  the  affected  nerves.  In 
extremely  rare  instances  the  pressure  on  the  cord  may  cause 
hemiplegia. 

Forcible  Correction  of  the  Deformity  of  Pott's  Disease. 
Calot's  Operation. — Forcible  correction  of  the  deformities  of 
the  spine  was  advocated  by  several  of  the  ancient  writers,  notably 
by  Hippocrates   and   by  Pare. 

In  1896  the  method  which  had  been  revived  by  Chipault  sev- 
eral years  before^  was  popularized  by  Calot,  of  Berck  sur  JNIer,^ 
who  claimed  that  it  was  particularly  adapted  to  the  treatment  of 
the  kyphosis  of  tuberculous  disease. 

In  brief,  the  operation  consisted  in  forcibly  straightening  the 
spine  by  horizontal  traction  and  by  direct  pressure  on  the 
deformity.  Afterward  the  patient  was  fixed  in  the  proper  atti- 
tude by  a  plaster  appliance  for  several  months.  After  an  extended 
trial  the  procedure  has  again  been  abandoned  and  the  detailed 
description  to  be  foimd  in  the  former  editions  has  been  omitted 
in  the  present  volume. 

The  Duration  of  the  Treatment  of  Pott's  Disease. — The  dura- 
tion of  the  treatment  must  depend  upon  the  extent  and  severity 
of  the  disease.     It  may  be  divided   into  two  periods:  one  during 

^  Travaux  de  neurologic  Chir.,  1895,  1896,  1897. 
»  Archiv.  "prov.  de  Chir.,  February,  1897,  t.  6,  n.  2. 


124  OR THOPEDIC  S  UR GER  Y 

which  the  disease  is  active,  when  fixation  is  indicated,  and 
a  stage  of  recovery,  during  which  supervision  is  required. 
During  the  first  stage  the  destructive  process  may  increase  the 
direct  deformity;  during  the  later  period  of  weakness  the  dis- 
tortion may  increase,  simply  because  of  the  general  inclination 
toward  deformity  and  because  of  the  atrophy  of  the  supporting 
muscles. 

Tuberculosis  of  the  spine  is  slow  in  its  progress,  and  recovery 
is  often  insecure.  The  course  of  the  disease  is  shortest  in  the 
cervical  region,  but  even  here  two  years  of  brace  treatment  will 
probably  be  required,  and  in  the  lower  region  double  this  time 
even  in  the  milder  type  of  cases.  Active  treatment  should  be 
continued  as  long  as  there  is  evidence  of  disease.  The  absence 
of  actual  pain  and  discomfort  i^  of  little  value  in  determining  the 
absolute  cure  if  braces  have  been  employed.  The  absence  of 
muscular  spasm  is  more  significant,  since  it  usually  persists  as 
long  a:s  the  disease  is  active.  The  presence  of  pain  on  passive 
motion  or  muscular  contraction  or  abscess  would,  of  course,  indi- 
cate the  necessity  of  further  treatment. 

Direct  palpation  is  of  some  value  in  determining  the  condition 
of  the  affected  part.  During  the  progressive  stage,  careful,  deep 
pressure  over  the  spinous  processes  may  show  greater  mobility  of 
those  involved  in  the  disease.  During  the  stage  of  repair  and 
consolidation  the  mobility  is  replaced  by  rigidity.  The  appear- 
ance of  the  kyphosis  has  some  significance.  In  the  early  stage  of 
the  disease  its  area  is  not  clearly  defined,  but  when  consolidation 
has  taken  place  its  extent  is  shown  by  the  rigid  vertebrae,  which 
stand  out  separated  from  the  remainder  of  the  spine  by  a  well- 
marked  sulcus,  which  is  much  deeper  below  than  above  the 
kyphosis. 

Even  when  the  disease  appears  to  be  cured,  removal  of  support 
should  be  gradual  and  tentative;  the  jacket  should  be  replaced 
by  the  corset,  or  the  brace  by  a  lighter  appliance;  then  support 
may  be  removed  at  night,  later  for  part  of  the  day,  and  at  last, 
after  many  months,  it  may  be  discarded.  Then  may  follow 
massage  of  the  atrophied  muscles  of  the  trunk  and  gentle  exercise. 

Such  careful  supervision  must  l)e  contimied  for  a  much  longer 
time  if  the  best  ultimate  result  is  to  be  attained,  for,  as  has  been 
mentioned,  one  should  guard  against  the  secondary  distortions, 
which  may  be  due  simply  to  weakness  and  to  the  uufavorable 
mechanical  conditions  induced  by  the  primary  deformity.  If 
curvatures  of  the  spine  are  so  common  among  normal  individuals 


TUBERCULOUS  DISEASE  OF  THE  SPINE  125 

how  much  more  Hkely  is  deformity  to  increase  when  the  trunk 
has  been  weakened  by  disease  and  by  long  disuse  of  the  muscles. 

This  secondary  increase  of  deformity  is  not  so  much  to  be 
feared  after  the  cure  of  the  disease  in  the  luml)ar  region,  because 
of  the  favorable  attitude  of  erectness,  nor  is  it  likely  to  be  marked 
after  cure  in  the  cervical  region  of  the  spine;  but  in  disease  of 
the  upper  and  middle  dorsal  region  support  must  be  continued 
long  after  recovery,  and  supervision  must  be  exercised  until  after 
the  period  of  adolescence,  if  increase  of  the  deformity  is  to  be 
prevented. 

Recurrence  of  Disease  and  Later  Effects  of  Deformity. — The 
disease  may  recur  after  an  interval  of  many  years  of  apparent 
cure,  and  such  recurrences  are  often  accompanied  by  the 
formation  of  an  abscess  or  by  paralysis. 

If  recovery  from  Pott's  disease  has  been  complete,  and  if  de- 
formity has  been  prevented,  the  condition  of  the  patient  is  to  all 
intents  normal;  but  if  the  course  of  the  disease  has  been  prolonged, 
and  if  the  deformity  is  great,  his  condition  is  abnormal.  He  is 
unfitted  for  ordinary  occupations,  and  comparative  comfort  is 
assured  only  by  constant  care.  Such  individuals  are  likely  to 
suffer  from  neuralgic  pain  about  the  weakened  spine  on  over- 
exertion or  whenever  the  general  condition  is  depressed  from  any 
cause.  In  such  cases  the  use  of  some  form  of  light  corset  adds 
to  the  comfort  of  the  patient. 

In  certain  instances  pain  localized  in  the  lateral  region  of  the 
trunk  may  be  caused  by  compression  of  an  intercostal  nerve,  or 
it  may  be  due  to  compression  of  the  tissues  between  the  last  rib 
and  the  pelvis.  In  several  cases  of  this  character  reported  by 
Goldthwait,  resection  of  a  portion  of  a  rib  at  the  seat  of  pain 
relieved  the  discomfort. 

Secondary  Deformities. — ^While  the  patient  is  under  treatment 
for  Pott's  disease  one  should  be  on  the  alert  to  prevent  other 
deformities  that  may  follow  the  general  weakness  and  restriction 
of  normal  functions.  One  of  these  is  the  weak  foot,  sometimes 
called  weak  ankle  or  flat-foot,  and  with  it  is  often  associated  a 
moderate  degree  of  knock-knee.  This  may  be  prevented  by  a 
shoe  of  proper  shape,  of  which  the  heel  antl  sole  are  thickened 
slightly  on  the  inner  side. 


CHAPTER   II. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE, 


S3rphilis. 


Fig.  75 


Syphilis,  in  the  inherited  or^in  the  later  stages  of  the  acquired 
form,  may  affect  the  bones  of  the  spine  and  cause  local  deformity 
and  S}Tnptoms  that  cannot  be  distinguished  from  those  of  Pott's 
disease. 

Diagnosis. — As  compared  with  tuberculosis  it  is  a  rare  disease 
of  the  spine. ^     Its  manifestations  are  likely  to  be  general  in  char- 
acter, the  deformity  of    the    spine 
being  but  one  of  many  evidences  of 
disease. 

If  syphilis  were  limited  to  the 
spine  and  simulated  the  symptoms 
and  the  deformity  of  Pott's  disease 
it  would  demand  the  same  local 
treatment.  Specific  remedies  should 
be  administered  when  one  has  reason 
to  suspect  the  presence  of  the  syph- 
ilitic taint,  even  if  the  local  disease 
appears  to  be  tuberculous  in  charac- 
ter. 

4^  Malignant  Disease  of  the  Spine. 

Malignant  disease  of  the  spine  is 
a  rare  affection,  particularly  so   in 
childhood.     Sarcoma  is  more   com- 
mon  than   carcinoma,  and   it  may 
,,..,.         ,   .         ,.       ,    affect  the   spine  primarily.     Carci- 

Vertieal   anteroposterior  section   of  i  r  *' 

the  lumbar  spine,  showing  deposit  of    noma  is  Jilmost  always  Secondary  to 

Kumrna   in   the   posterior  part  of   the  .  i  i  ii  • 

third  and  fourth  vertebra.     (After    a  primary  tumor  elscwhcre,  the  spme 
Fourmer.)  becoming  involved  by  metastasis  or 

by  contiguity.     Scl)lesinger^  in  3720  cases  of  carcinoma    found 
secondary  growths  in  the  spine  in  54. 


'  Ja-sinski,  Archiv  f.  Dermat.  u.  Sypli.,  Bd.  xxiii.,  S.  400. 

'  Buckley,  Journal  of  Nervous  and  Mental  Disease,  April,  1902. 


NON-TUBERCVLOUS  AFFECTIONS  OF  THE  SPINE       127 

Diagnosis. — Malignant  disease  differs  from  tuberculosis  of  the 
spine  in  that  its  symptoms  are  usually  more  severe;  the  pain  is 
usually  persistent,  and  it  is  not  relieved  by  support  or  recum- 
bency, as  is  that  of  Pott's  disease.  The  constitutional  symptoms 
are  more  marked  and  the  steady  progress  of  the  disease  toward 
a  fatal  termination  is  soon  apparent.  Locally,  the  angular  de- 
formity is  usually  slight,  and  it  may  be  absent.  Not  infrequently 
the  tumor  may  be  palpated  through  the  abdominal  wall. 

Paralysis  is  a  frequent  and  often  an  early  symptt^m.  In  a 
case  of  melanotic  sarcoma  of  the  spine  in  a  boy  aged  twelve  years, 
complete  paralysis  of  motion  and  sensation  in  the  lower  extremities 
preceded  noticeable  symptoms  pointing  to  the  local  disease. 

As  has  been  stated,  carcinoma  is  almost  always  secondary  to 
disease  elsewhere;  thus,  if  after  the  operation  for  the  removal  of 
carcinoma  symptoms  of  disease  of  the  spine  appear  one  should 
suspect  this  complication. 

Malignant  disease  of  the  spine  is  a  fatal  affection,  and  the 
treatment  can  be  but  palliative. 


Acute  Osteomyelitis  of  the  Spine. 

Infectious  osteomyelitis  of  the  spine  is  comparatively  uncommon. 

Symptoms. — The  symptoms  are  similar  to  those  of  acute  infec- 
tious processes  elsewhere,  and  are  characterized  by  sudden  onset, 
with  pain,  fever,  and  constitutional  depression.  There  are  local 
pain  and  tenderness  about  the  spine  and  in  many  instances 
distention  of  the  veins  in  the  neighborhood  caused  by  interfer- 
ence with  the  circulation  by  septic  thrombosis.  Abscess  quickly 
forms,  and  paralysis  from  the  rapid  extension  of  the  disease  is 
a  common  complication.^  The  symptoms  due  to  pyogenic  in- 
fection and  to  deep-seated  abscess  are  often  pysemic  in  character 
and  necrosis  of  the  affected  vertebral  bodies  may  result  in  the 
formation  of  large  sequestra. 

In  sixty-one  cases  collected  from  literature  by  Hunt,^  the 
situation  of  the  disease  was  as  follows: 

Cervical  region 12 

Thoracic  region 15 

Lumbar  region 24 

Sacral  region 10 

Either  the  bodies  or  the  arches  of  the  vertebrae  may  be  primarily 
involved. 

>  Medical  Record,  April  23,  1904. 


128  ORTHOPEDIC  SURGERY 

The  cause  of  the  infection  in  fifteen  of  the  twenty  cases  examined 
was  the  Staphylococcus  aureus. 

According  to  Grisel.^  in  forty  of  fifty-six  cases  reported,  the 
patient  died  of  general  infection,  pleuropneumonia,  or  meningitis 
before  the  diagnosis  was  made  and  before  abscess  had  appeared. 
The  mortality  was  about  56  per  cent. 

Recovered.  Died. 

Suboccipital   region 1  4 

Cervical 2  2 

Dorsal 7  3 

Lumbar 13  15 

Sacral 0  6 

23  30 

A  more  localized  and  more  chronic,  and  of  course  far  less  dan- 
gerous, form  of  osteomyelitis  may  occur,  and  abscess  may  be  the 
first  sign  of  the  disease.  In  all  cases  of  this  character,  whether 
acute  or  chronic,  other  bones  or  joints  or  other  tissues  are  often 
involved,  and  in  many  instances  an  infected  wound  or  discharging 
ear,  for  example,  may  indicate  the  source  of  infection. 

Treatment. — The  treatment  consists  in  the  immediate  evacua- 
tion and  drainage  of  the  abscess,  the  removal  of  the  necrosed 
bone  if  possible,  and  in  supporting  the  spine  during  the  subse- 
quent stage  of  weakness. 


Actinomycosis  of  the  Spine. 

Actinomycosis  of  this  region  is  extremely  uncommon,  the 
spine  having  been  involved  secondarily  in  about  2  per  cent, 
of  the  reported  cases.^  The  diagnosis  may  be  made  by  the 
microscopic  examination  of  the  discharge  from  the  sinuses  that 
almost  always  form  when  bone  is  affected. 


Injury  of  the  Spine. 

Severe  sprains  or  fractures  may  simulate  disease  very  closely, 
and  in  some  instances,  particularly  of  injury  of  the  cervical  region, 
the  diagnosis  is  practically  impossible  until  after  treatment  by 
support  ami  fixation  has  been  applied,  when,  as  a  rule,  if  disease 
be  absent,  the  symptoms,  even  though  of  long  standing,  (|uickly 
subside. 

■■  Revue  d'orthopi^die,  September,  1003. 

'  lOrviiiK,  .Johns  HcjpkiriH  iiullctin,  November,  1902. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      129 

Fracture  of  the  spine  in  the  middle  region  may  result  in  angu- 
lar deformity,  and  when  proper  support  has  been  neglected, 
symptoms  of  pain  and  weakness,  similar  to  those  of  Pott's  disease, 
may  persist  indefinitely. 

Sudden  forcible  compression  of  one  or  more  of  the  vertebral 
bodies  without  displacement  and  without  severe  immediate  s^nnp- 
toms,  other  than  the  slight  deformity,  may  be  the  result  of  injury, 
especially  falls  from  a  height.  These  cases  are  not  uncommon, 
and  as  the  severity  of  the  injury  is  not  often  recognized,  the  local 
deformity,  which  may  not  attract  attention  until  several  weeks 
after  the  accident,  combined  with  stiffness  and  weakness,  lead  to 
the  mistaken  diagnosis  of  Pott's  disease. 

Rupture  of  spinal  ligaments  may  be  caused  by  forced  forward 
bending  of  the  spine.  The  resulting  deformity  and  weakness  re- 
semble the  symptoms  caused  by  a  crush  of  one  of  the  vertebral 
bodies.  A  number  of  cases  have  been  described  by  Painter  and 
Osgood.^ 

Traumatic  Spondylitis. — KummelP  has  described  a  form  of 
rarefying  ostitis  of  the  spine  of  non-tuberculous  origin,  appar- 
ently caused  by  injury.  It  is  characterized  by  symptoms  of  pain 
and  weakness  referred  to  the  back,  and  by  a  pronounced  rounded 
kyphosis  of  the  dorsal  region.  Motor  disturbances  of  the  lower 
extremities  are  frequent.  This  is  easily  explained  by  the  fact 
that  in  cases  of  this  character  fracture,  disorganization  of  the 
disks,  rupture  of  ligaments,  hemorrhage  beneath  the  longitudinal 
ligament,  into  the  muscles  or  into  the  spinal  canal,  have  been  dem- 
onstrated at  autopsy.  Indirect  injury,  shock  to  the  nervous  appa- 
ratus and  the  like  may  cause  complicating  symptoms  in  addition.^ 

Kummell's  cases  do  not  differ  particularly  from  those  of  injury 
that  have  been  described.  In  fact,  in  the  neglected  cases  of 
injury  of  the  spine  the  pain  and  weakness  may  persist  indefi- 
nitely, and  the  deformity  may  increase.  In  certain  instances 
there  may  be  a  secondary  infection,  tuberculous  or  ortherwise, 
at  the  seat  of  injury,  and  in  others  the  injury  may  be  the  exciting 
cause  of  spondylitis  deformans,  but  such  results  are  unusual. 

Treatment.— In  all  such  cases,  and  whenever  weakness  of  the 
spine  persists,  antl  when  motion  causes  pain,  a  support  should  be 
employed  as  in  the  treatment  of  Pott's  disease.  If  possible, 
deformity  if  of  recent  origin  should  be  corrected,  in  part  at  least, 

'  Boston  Medical  and  Surgical  Journal,  January  2,  1902. 
*  Deutsche  med.  Woch.,  1895,  No.  11. 

3  Reuter,  Archiv  f.  Ortli.  u.  UnfallchirurKie,  B.  ii.,  H.  2,  1904. 
9 


130  ORTHOPEDIC  SUBOEEY 

either  by  direct  traction  or  by  recumbency  before  the  support 
is  appHed.  ^Massage  and  gentle  exercise  are  of  value  during  the 
period  of  recovery.  Clinical  evidence  indicates  that  repair  is  slow, 
support,  therefore,  should  be  used  for  at  least  six  months  and 
for  a  much  longer  time  if  the  injury  is  of  the  middle  dorsal  region 
in  which  the  tendency  to  postural  deformity  is  so  marked. 

Fig.  76 


Rhachitic  kyphosis. 

The  Rhachitic  Spine. 

The  rhachitic  spine  has  been  described  in  the  consideration 
of  the  differential  diagnosis  of  Pott's  disease.  It  most  often 
develops  during  the  first  or  second  year  of  life,  in  children  who  sit 
the  greater  part  of  the  time;  it  is,  in  fac;t,  simply  an  exaggeration 
of  the  contour  which  is  normal  in  the  sitting  posture.  The  typi- 
cal rhachitic  kyphosis  is  thus  a  rounded  projection  of  the  lower 
region  of  the  spin(!,  which  is  more  or  less  rigid  accor<h"Mg  to  its  dura- 
tion. If  the  deformity  is  extreme  there  may  l)e  a  compensatory 
baxikward  inclination  (jf  the  head,  which  inay  be  accompanied 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      ]31 

by    contraction    of    the    posterior    group    of    muscles,  "cervical 
opisthotonos." 

Treatment. — Aside  from  the  constitutional  treatment  of  the 
rhachitic  condition,  and  from  the  measures  that  should  be  employed 
to  improve  the  nutrition  of  the  muscles  in  general,  the  indica- 
tions are  to  overcome  the  rigidity  and  the  limitation  of  motion 
of  the  spine;  to  support  it,  if  necessary,  during  the  stage  of  weak- 
ness; and  to  remove,  if  possible,  the  predisposing  causes  of  the 
deformity. 

The  correction  of  the  deformity  may  be  accomplished  by  mas- 
sage and  by  direct  manipulation  of  the  spine.  The  child  is 
placed,  face  downward,  on  a  table;  one  hand  is  placed  on  the 
projection,  and  with  the  other  the  legs  are  raised  to  throw 
the  spine  into  a  position  of  overextension.  This  stretching  is 
performed  slowly  and  carefully  over  and  over  again  at  morning 
and  night,  and  the  manipulation  is  followed  by  thorough  mas- 
sage of  the  muscles.  If  the  deformity  is  marked  and  if  the  gen- 
eral rhachitic  process  is  still  active,  the  recumbent  posture,  on  a 
light  frame,  in  an  attitude  of  overextension  may  be  indicated 
as  described  in  the  treatment  of  Pott's  disease. 

For  older  subjects  some  form  of  light  back  brace  may  be  suffi- 
cient in  connection  with  the  massage,  and  systematic  correction 
of  the  deformity. 

The  Natural  Cure. — It  may  be  stated  that  the  rhachitic  spine  is 
to  a  certain  extent  corrected  when  the  erect  posture  is  assumed, 
by  the  inclination  of  the  pelvis  and  accompanying  lordosis.  This 
natural  cure  is,  however,  often  rather  a  distribution  of  deformity 
than  a  cure,  for  the  upper  part  of  the  projection  may  remain  as 
an  exaggeration  of  the  normal  dorsal  kyphosis  balanced  by  an 
exaggerated  lordosis,  "the  rhachitic  attitude."  In  other  instances 
the  persistence  of  the  lumbar  kyphosis  may  induce  a  compen- 
satory flattening  of  the  normal  dorsal  kyphosis.  Thus,  rhachitis 
may  cause  the  so-called  fat  hack  as  well. 

It  may  be  mentioned  that  rotary  lateral  curvature  of  the  spine, 
one  of  the  common  deformities  induced  by  rhachitis,  is  far  more 
serious  than  the  anteroposterior  curvature,  with  which  it  is  occa- 
sionally combined.     Its  treatment  is  considered  in  Chapter  HI. 


132  ORTHOPEDIC  SVRGERY 


Infectious  Disease  of  the  Coverings  or  Articulations   of 
the  Spine.    "The  Typhoid  Spine." 

During  tlie  course  of  or  during  convalescence  from  typhoid 
fever,  and  occasionally  after  apparent  recovery  from  the  disease, 
symptoms  of  pain,  weakness,  and  stiffness  of  the  back  may  ap- 
pear. These  are  caused  apparently  by  secondary  infection  of 
the  fibrous  coverings  and  attachments  of  the  spine,  similar  to  the 
more  common  but  more  severe  forms  of  periostitis  of  the  tibia  or 
other  bones,  from  the  same  cause.  There  is  usually  pain  on 
motion,  reflected  along  the  nerves.  In  some  instances  this  is 
extreme,  and  there  may  be  accompanying  muscular  "cramps  "  and 
spasm  in  the  limbs,  local  muscular  spasm,  and  pain  on  pressure 
over  the  affected  vertebrae.  The  temperature  is  often  above  nor- 
mal, with  irregular  and  sometimes  extreme  fluctuations  in  severe 
cases. 

In  many  instances  a  neurotic  element  is  present,  induced, 
doubtless,  by  the  preceding  disease.  The  complication  is  most 
common  in  young  adults. 

In  six  of  sixty-eight  cases  tabulated  by  Wurtz^  the  patients 
were  children,  and  several  of  this  class  have  come  under  my 
observation. 

Diagnosis. — The  diagnosis  is  usually  made  clear  by  the  history 
of  the  disease  of  which  it  is  a  complication. 

Treatment. — The  treatment  should  be  symptomatic.  During 
the  active  stage,  if  pain  is  severe,  the  patient  should  be  kept  in 
the  recumbent  position,  if  necessary  on  the  stretcher  frame. 
Locally,  the  application  of  the  Paquelin  cautery  is  of  service. 
As  soon  as  is  practicable  a  back  brace  or  other  support  should 
be  applied,  which  should  be  worn  until  the  symptoms  have 
subsided.  Recovery  may  be  predicted,  the  duration  of  the  symp- 
t(ims  averaging  about  six  months.  Slight  restriction  of  motion 
may  persist  in  the  more  severe  type  of  cases. 

Tliis  description  appUes  particularly  to  a  class  of  cases  of  a 
mild  type  described  by  Gibney"  as  typhoid  spine.  Disease  of  the 
spine  complicating  typhoid  fever  was  first  described  by  Maison- 
neuve  in  183.5.  Terrillon'*  classifies  the  lesions  of  typhoid  infec- 
tion of  the  spine  as: 

'  KoHtori  Medical  and  Surnifial  Jcjurnal,  June  20,  1902. 
2  (jibney,  Tr.  Atn.  Ortli.  AHHrjc.,  v.  ii. 
■■'  Le  Prog.  M<!d.,  April  12,  1884. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      133 

1.  Simple  periostitis. 

2.  Periostitis  with  subperiosteal  abscess. 

3.  Periostitis  with  ostitis. 

In  eight  of  twenty-six  cases  investigated  by  Lord^  local  deformity 
indicated  a  destructive  process. 

Symptoms  resembling  those  described  may  follow  other  forms 
of  contagious  disease,  notably  scarlet  fever,  but,  as  a  rule,  they 
are  much  less  persistent  and  severe. 


'  Infectious  Arthritis  of  the  Spine. 

"Gonorrhoeal  rheumatism"  of  the  spine  is  uncommon.  Its 
symptoms  and  pathology  resemble  those  of  the  typhoid  spine. 
Anchylosis  is,  however,  more  common  as  a  result  than  after  other 
forms  of  infection;  in  fact,  gonorrhoea  is  apparently  one  of  the 
more   common   causes   of  spondylitis   deformans. 

The  treatment,  aside  from  that  of  the  exciting  cause,  is  symp- 
tomatic.    Local  support  is  indicated  in  many  instances. 

Arthritis  of  the  Suboccipital  Region. — The  articulations  of  the 
occipitoaxoid  region  are  sometimes  affected  by  what  appears  to  be 
a  form  of  acute  or  subacute  infectious  arthritis  similar  in  char- 
acteristics to  acute  rheumatism.  It  may  follow  tonsillitis,  diph- 
theria, or  other  contagious  disease.  It  may  be  distinguished  from 
tuberculous  disease  by  its  acute  onset  and  from  acute  torticollis 
by  the  fact  that  all  motions  are  restricted. 

Treatment. — The  treatment  consists  in  support  during  the 
acute  stage,  followed  by  massage,  manipulation,  and  exercise  to 
overcome  the  subsequent  stiffness. 


Spondylitis  Deformans. 

Synonjrms. — Osteoarthritis  of  the  spine;  rheumatism  of  the 
spine;  spondylose  rhizomelique;  stiffness  of  the  vertebral  column. 
Spondylitis  deformans  is  chronic  progressive  affection  of  the  spine 
terminating  in  anchylosis  and  deformity. 

Pathology. — ^The  disease  is  apparently  a  chronic  inflammation 
which  affects  primarily  the  ligaments  and  the  periosteal  coverings 
of  the  spine,  a  fotm  of  ossifying  periostitis  which  binds  the  ver- 
tebrte  firmly  to  one  another   (Fig.    77).     It  may  begin    on  the 

'  Boston  Medical  and  Surgical  Journal,  June  26,  1905. 


134 


ORTHOPEDIC  SURGERY 


lateral  or  on  the  anterior  aspect  of  the  spine;  it  may  be  limited 
to  a  particular  region,  but  in  most  instances  it  eventually  involves 
the  entire  spine  and  often  the  articulations  of  the  ribs  as  well. 
The  intervertebral  disks  atrophy  and  the  spine  becomes  anchy- 
losed.  In  some  instances  the  margins  of  the  cartilages  prolif- 
erate and  become  ossified  in  a  manner  characteristic  of  osteo- 
arthritis of  the  joints. 


Fig.  77 


SlJoiiiJyliti«  (leforniaiis  (osteoarthritis).      (Goldthwait.) 


Under  the  general  term  of  spondylitis  deformans  are  included, 
in  all  probal)ility,  several  varieties  of  disease,  for  example: 

1.  The  affection  of  the  spine  may  be  simply  one  of  the  mani- 
festations of  polyarthritis — "rheumatoid  arthritis"  of  the  spine. 

2.  The  spine  may  be  involved  together  with  one  or  more  of 
the  adjacent  joints  which  present  the  characteristic  symj)toms  of 
the  so-called  hypertrophic  form  of  arthritis  deformans — osteo- 
arthritis of  the  spine.  'J'his  form  lias  been  designated  by  Marie 
sponflylose     rhi/onK-lique,     spondyios-spine,     rhizo-root,     melos- 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      135 

extremity,   signifying   a   disease   of   the   spine   together   with   the 
adjoining   "root"   joints/ 

3.  The  disease  may  be  limited  to  the  spine,  and  in  such  cases 
it  appears  to  be  clinically  distinct  from  characteristic  general 
arthritis  or  atrophic  or  hypertrophic  arthritis.  It  may  follow  acute 
polyarthritis,  it  may  be  induced  apparently  by  gonorrhoea  or  by 
other  forms  of  infection,  or  by  injury — "  traumatic  spondylitis.'* 
It  may  begin  acutely,  or  it  may  be  chronic  in  character  and  pro- 
Fir 


Spondylitis  deforniaus,  showitip;  the  characteristic  curvature  of  the  spine.  Ape  of  the 
patient,  twenty-three  years.  Duration  of  the  disease  three  years;  cause  unknown.  No 
other  joints  involved. 

gress  slowly?  It  may  be  limited  to  a  particular  section  of  the 
spine,  although,  as  a  rule,  the  other  regions  are  progressively  in- 
volved. 

The  last  class  of  limited  spondylitis  is  more  often  seen  in  young 
adults  from  twenty  to  forty  years  of  age,  and  in  at  least  SO  per 
cent,  of  the  cases  the  patients  are  males. 

1  Marie,  Revue  de  Mt5d.,  1898,  vol.  xviii. 

'^  Bechterew,  Neurol.  Centralbl.,  vol.  ii.  p.  426.  Senator,  Berlin,  klin.  Wochcn,,  No- 
vember 20,  1897. 


136 


ORTHOPEDIC  SURGERY 


Symptoms. — In  the  ordinary  cases  there  is  usually  an  acute 
onset  from  which  the  patient  dates  the  beginning  of  his  trouble, 
often  so-called  hunbago,  followed  by  a  gradually  increasing  stiff- 
ness of  th?  spine  and  accompanying  deformity.  The  patient  com- 
plains of  stiffness,  weakness,  pain  in  the  loins,  and  of  pain  radi- 


FiG.  79 


Fig.  so 


PiH 

r  _^j^B 

W} 

^^K^-4t 

yd 

mjMM 

C    m 

I^SP^^H 

1 

Spondylitis  deformans,  illustrating 
the  characteristic  deformity.  Age  of 
the  patient,  thirty  years.  ,Si)ine 
rigid,   with  the  exception  of  the  oc- 

cipitoaxoid    articulation.      Duration  Spondylitis  deformans  in  a  child, 

two     years;    cause    unknown.       No 
joints  involved. 

ating  forward  along  the  ribs;  sometimes  of  weakness  in  the 
limbs,  headache,  nervousness,  and  the  like — .symptoms  that  may 
be  explained  in  part  by  the  inflammatory  process  and  by  impli- 
cation of  the  nerve  roots,  and  in  part  by  an  act^ompanyiug  neuras- 
thenia. The  dire(;t  symptoms  are  increased  by  jars,  which  are 
exaggerated  by  the  inelasticity  of  the  spine.  The  disea.se  is 
asually  progressive,  and  terminates  finally  in  complete  rigidity 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      137 

of  the  spine,  which  is  bent  into  a  long  kyphosis,  most  marked 
in  the  upper  dorsal  region,  the  lumbar  lordosis  being  obliterated 
in  many  instances  (Fig.  79). 

The  straightening  of  the  spine  in  the  middle  and  lower  region 
exaggerates  the  forward  thrust  of  the  neck,  and  in  some  instances 
the  patients  complain  of  a  disturbance  of  equilibrium,  especially 
of  a  tendency  to  fall  forward. 

When  the  disease  is  limited  to  the  spine  or  to  the  spine  and 
one  or  more  of  the  larger  joints,  the  occipitoaxoid  articulations 
are  not  usually  involved;  but  in  the  general  form  of  the  disease — 
"  rheumatoid  arthritis  " — they  are  often  primarily  affected. 

The  types  of  the  disease  may  be  illustrated  by  a  brief  descrip- 
tion of  five  cases  recently  under  observation. 

Case  I.  Rheumatoid  Arthritis  of  the  Spine. — In  this  case, 
that  of  a  boy  ten  years  of  age,  there  was  characteristic  general 
rheumatoid  (atrophic)  arthritis  that  involved  nearly  every  joint 
of  the  body.  The  entire  spine,  even  including  the  occipito- 
axoid joints,  was  rigid  and  the  head  was  fixed  in  an  attitude  of 
extreme  torticollis. 

Case  II.  Osteoarthritis  of  the  Spine  ("spondylose  rhizo- 
m^lique"). — A  man  aged  forty-six  years,  after  repeated  attacks 
of  so-called  rheumatism  involving  the  larger  joints,  gradually 
became  disabled  because  of  pain  and  stiffness  of  the  back  and 
because  of  his  inability  to  stand  erect.  In  this  case  there  was 
complete  anchylosis  of  the  spine,  except  of  the  small  joints  of  the 
cervical  region,  and  in  addition  the  right  thigh  was  flexed  upon 
the  body  at  such  an  angle  that  the  patient  could  walk  only  with 
an  exaggerated  stoop.  The  joints  of  the  feet  were  slightly  in- 
volved also.  No  cause  other  than  exposure  to  cold  and  dampness 
could  be  assigned.  The  symptoms  were  of  two  years'  duration, 
periods  of  comfort  alternating  with  disabling  attacks  of  "rheu- 
matism." 

Case  III.  Spondylitis  Deformans. — The  spine  of  this  patient, 
a  man  aged  forty-six  years,  was  absolutely  anchylosed  in  the  char- 
acteristic position.  The  occipitoaxoid  joints  were  not  involved. 
Fourteen  years  before  he  had  suffered  from  a  severe  and  pro- 
longed attack  of  "inflammatory  rheumatism,"  affecting  nearly 
every  joint,  but  not  the  spine,  and  during  a  succeeding  period 
of  nine  years  he  had  been  disabled  several  times  from  the  same 
cause.  Each  illness  was  coincident  with  gonorrhoea.  Five  years 
before  examination  the  "rheinnatism"  had  involved  the  spine, 
and  since  then  he  had  suffered  from  persistent  "lumbago."     Grad- 


]  38  OF THOPEDIC  S URGER  T 

ually  the  stiffness  of  the  spine  had  increased,  bnt  during  this 
time  he  had  been  free  from  gonorrhoea,  and  from  rheiuiiatism 
as  welL  The  joints  were  normal  in  appearance  and  function. 
This  patient  suffers  principally  from  nervovisness  and  irritability; 
he  is  easily  startled;  he  feels  as  if  his  forehead  was  clasped  by  a 
tight  band.  His  direct  s\iiiptoms  are  pain  in  the  loins  and  pain 
radiating  under  the  shoulder-blades,  increased  by  walking  or  by 
jars.  His  equilibriiun  is  disturbed  by  the  forward  projection  of 
the  head  and  by  the  obliteration  of  the  normal  lordosis,  so  that 
he  feels  himself  constantly  inclined  to  fall  forward,  whether  he 
is  sitting  or  standing. 

Case  IV, — In  another  case  very  similar  to  this,  in  a  man  aged 
thirty  years,  the  spine  had  become  rigid  in  a  few  months.  The 
patient  ascribed  the  disease  to  sleeping  out-of-doors.  There 
was  in  this  case  coincident  tuberculous  disease  of  the  lungs. 
And  in  this  instance  the  cause  of  the  deformity  may  have  been 
superficial  tuberculous  disease. 

Case  V. — A  man  aged  sixty-two  years,  presenting  the  char- 
acteristic deformity  and  symptoms  of  the  subacute  type,  gave  the 
following  account  of  the  affection:  Fifteen  years  before  he  had 
suffered  from  "chronic  lumbago."  The  pain  and  stiffness,  at 
first  limited  to  the  lower  region  of  the  spine,  had,  with  interven- 
ing periods  of  remission,  gradually  ascended,  and  at  the  time  of 
examination  the  cervical  region  was  the  seat  of  the  more  active 
process.  He  had  been  treated  by  internal  remedies,  by  baths,  and 
by  change  of  climate,  without  avail.  He  knew  he  had  the  "old 
man's  stoop,"  but  he  was  surprised  to  learn  that  the  source  of 
his  symptoms  was  a  disease  of  the  spine.  The  spine  was  rigid, 
although  not  anchylosed,  as  indicated  by  the  discomfort  on  chang- 
ing from  one  position  to  another.  The  occipitoaxoid  articu- 
lations and  the  other  joints  were  free  from  disease. 

This  subacute  form  of  the  affection  is  very  common,  and,  as  in 
this  instance,  the  patients  are  usually  treated  for  rheumatism, 
rrmscular  or  otherwise,  for  many  years  before  the  true  diagnosis 
is  made. 

Treatment. — The  local  treatment  is  symptomatic.  Massage 
of  the  muscles,  hot  baths,  and  the  like  may  add  to  the  comfort 
of  the  patient,  but  violent  exercise  or  passive  movements  of  the 
spine  are  harmful.  Support  is  always  indicated  during  the  pro- 
gressive stage  of  the  affection,  and  it  is  the  only  efficient  remedy. 
The  support  may  be  in  the  form  of  a  light  brace  or  jacket.     It  is 


NON- TUBERCULO US  A FFECTIONS  OF  THE  SPINE      \ 3 9 

particularly  efficacious  when  the  disease  is  limited  to  the  lower 
and  middle  regions  of  the  spine.  In  such  cases  under  efficient 
protection  the  muscular  spasm  subsides  and  motion  returns  in 
some  degree.  Even  in  progressive  cases  one  may  hope  to  pre- 
serve the  lumbar  lordosis,  and  thus  lessen  the  general  effect 
of  the  deformity  when  the  spine  becomes  rigid.  In  certain 
instances  in  which  anchylosis   is   not  established,  force  may  be 

Fic  81 


Extreme  posterior  curvature  of  t  he  spine  in  ;i<lolescence,  showing  retniction  of  the  abtlonien. 
This  deformity  may  be  mistaken  for  spondylitis  deformans. 

employed  to  improve  the  contour  of  the  spine,  particularly  with 
the  aim  of  re-establishing  the  lumbar  lordosis,  and  thus  enabling 
the  patient  to  stand  erect.  The  patient  learns  by  experience 
what  exercises  or  postures  increase  the  discomfort,  and  these  should 
be  avoided  if  possible.  The  application  of  a  cautery  is  often  of 
service,  and  self-suspension  at  intervals  may  relieve  the  dragging 
sensation  in  the  muscles.     Rubber  heels   are   useful    in   lessen- 


140  ORTHOPEDIC  SURGERY 

ing  the  jar.  As  has  been  stated,  in  some  cases  the  disease 
remains  locaHzed,  but  ordinarily  it  extends  along  the  spine. 
Allien  a  part  of  the  spine  becomes  firmly  anchylosed  the  local 
discomfort  lessens  or  ceases,  and  is  transferred  to  the  part  where 
the  process  is  still  advancing. 

Kyphosis  of  Adolescents. — A  form  of  extreme  kyphosis  accom- 
panied bv  stiffness  and  discomfort  is  sometimes  seen.  It  appears 
to  be  a  static  deformity  induced  by  overwork  in  rapidly  growing 
adolescents,  which  finally  becomes  fixed  by  accommodative 
changes  in  the  bones  and  neighboring  tissues.  It  can  hardly 
be  classified  with  spondylitis  deformans,  although  there  may  be 
some  difficulty  in  distinguishing  between  the  two  (Fig.  81).  In 
favorable  cases  partial  rectification  of  the  deformity  by  force 
(the  Calot  operation)  is  indicated.  Afterward  support,  manipula- 
tion, and  exercises  should  be  employed. 


Osteitis  Deformans. 

Sjnionym. — Paget's   disease. 

Osteitis  deformans  is  a  general  disease  characterized  by  hyper- 
trophy and  softening  of  the  bones.  The  deformity  of  the  spine 
is  similar  to  that  of  spondylitis  deformans,  but  the  rigidity  is  not 
as  marked,  and  the  discomfort  is  far  less  than  in  this  affection. 
The  disease  is  described  elsewhere. 

Tabetic  Deformity  of  the  Spine. — In  rare  instances  deformity 
of  the  spine,  either  posterior  or  lateral,  appears  as  a  complication 
of  locomotor  ataxia.  Fifteen  cases  are  recorded.^  The  character- 
istics of  this  form  of  osteoarthropathy  are  described  elsewhere. 


Spondylolisthesis. 

Spondylolisthesis  is  a  deformity  in  which  the  body  of  one  of 
the  lower  lumbar  verte})rcfi,  most  often  the  fifth,  is  displaced  for- 
ward and  downward  (Fig.  82).  At  this  point  the  ligamentous 
support  is  weakest  and  the  upper  surface  of  the  sacrum  slants 
forward.  In  certain  instances  the  spinous  process  may  remain 
in  its  normal  position,  while  the  lamina;  become  elongated  or 
separated  from  the  body  (Fig.  82).     The  condition  was  first  de- 

'  Cornell,  Bulletin  of  .Johns  Hopkins  HoHpital,  October,  1902. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      HI 

Fig.  82 


Small  pelvis  of  Prague  (median  section).'    Instance  of  slight  forward  displacement  of  the 
body  of  the  fifth  lumbar  vertebra.     (Neugebauer.) 


scribed  by  Killian  in  1854,  and  it  was 
thoroughly  investigated  by  Neugebauer 
in  1890. 

The  causes  are  congenital  malforma- 
tion, injury,  overstrain,  and  possibly 
disease  of  the  lumbosacral  articula- 
tion. Lane  states  that  slighter  degrees 
of  the  deformity  are  often  observed 
among  laborers.  The  trunk  is  displaced 
forward  and  downward  in  its  relation 
to  the  pelvis.  Thus  the  inclination  of 
the  pelvis  is  lessened  or  lost  and  the 
lumbar  lordosis  is  absolutely  or  rela- 
tively increased  (Fig.  83).  The  sacrum 
projects  and  the  space  between  the 
ribs  and  the  iliac  crests  is  diminished. 

The  typical  deformity  is  most  often 
seen  in  women;  in  fact,  its  chief  interest 
lies  in  its  effect  upon  childbirth.  As  a 
rule,  as  has  been  stated  in  the  preced- 
ing section,  an  increase  of  the  lumbar 
lordosis  is  usually  attended  by  a  certain 
degree  of  discomfort,  pain,  and  limita- 
tion of  forward  bending.  The  patients 
are  weak  or  easily  fatigued.  In  some 
instances  disturbance  of  equilibrium 
is  a  prominent  symptom.  Not  infre- 
quently the  deformity  induces  a  swag- 
gering gait  resembling  that  of  bilateral 


Fio.  83 


SpcindyKilistliesis  in  an  atlolcs- 
cent,  induced  apparently  by  over- 
work. Symptoms  :  inability  to 
bend  forwaril  and  pain  on  fatigue, 
radiating  down  back  of  the  thighs. 


142  ORTHOPEDIC  SURGERY 

congenital  dislocation  of  the  hips.  Such  cases,  or  those  in 
which  displacement  is  the  result  of  disease  or  injury,  particularly 
if  the  deformity  is  progressive,  may  require  orthopedic  treatment 
by  braces  or  other  support.  In  the  milder  type,  exercises  and 
posture  are,  as  a  rule,  sufhcient. 


Relaxation  of  the  Pelvic  Joints. 

Goldthwait'  has  called  attention  to  the  persistent  disability  that 
may  follow  the  relaxation  of  the  sacroiliac  joints  most  often 
incidental  to  pregnancy,  but  induced  occasionally  by  a  variety 
of  other  conditions,  the  symptoms  resembling  closely  those 
of  spondylolisthesis.  The  inclination  of  the  pelvis  is  lost  and 
the  sacrum  becomes  perpendicular.  The  treatment  consists  in 
re-establishing  the  lumbar  lordosis  by  means  of  the  brace  or 
plaster  support,  thus  forcing  the  sacrum  forward  to  its  normal 
position.     In  milder  cases  a  pelvic  girdle  may  be  sufficient. 


Pain  in  the  Lower  Part  of  the  Back. 

Discomfort  in  the  lumbar  region  of  the  character  of  tire,  weak- 
ness, or  even  of  actual  pain  is  sometimes  an  accompaniment  of 
disease  or  displacement  of  the  pelvic  or  abdominal  organs.  Pain 
in  this  region  is  also  a  common  symptom  among  overworked 
women.  It  may  be  induced  also  by  weakness  or  deformity 
of  the  feet.  It  is  particularly  troublesome  when  for  any 
reason  the  lumbar  lordosis  is  exaggerated  temporarily,  as  during 
pregnancy,  or  permanently,  as  a  compensatory  deformity  for 
dorsal  Pott's  disease,  or  because  of  flexion  of  the  thigh  after  hip 
disease. 

As  a  result  of  strain  or  other  injury  symptoms  of  pain  and  weak- 
ness in  the  lumbar  region,  increased  by  sudden  motions  or  over- 
exertion, may  be  persistent  and  disabling.  Such  cases  are  often 
classed  as  chronic  lumbago,  but  it  is  probable  that  there  is  in 
many  instances  a  distinct  injury  of  the  ligaments  or  deep  muscles 
of  the  spine  or  strain  or  displacement  at  the  sacroiliac  articula- 
tion, aggravated,  it  may  be  in  certain  cases,  by  rheumatism  or 
other  general  affection  of  like  (;haracter. 

Lufllofi'^  has  recently  called  attention  to  the  fact  that  persistent 

'  Goldthwait,  anrl  Ohkoo(I,  Boston  McA.  and  Sihk.  Jour.,  May  25  and  Juno  1,  190.5. 
*  FortH.  auf  d.  fiebieteder  Koftnt,Kf;nntralilen,  ]Jaii<l  ix.,  Hoft  3. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      143 

pain  about  the  sacrum  following  falls  or  other  injuries  may  be 
explained  in  many  instances  by  a  slight  degree  of  traumatic 
spondylolisthesis. 

The  treatment  must  be  primarily  directed  to  the  condition  of 
which  the  pain  is  a  symptom. 

When  motion  causes  pain  and  when  the  symptoms  are  per- 
sistent, as  in  the  lumbago  type  of  cases,  whether  due  to  injury  or 
to  inflammation  of  the  fibrous  or  muscular  tissues,  support  is  in- 
dicated, the  Knight  brace  or  plaster  corset  being  convenient 
forms.  During  the  more  acute  stage  the  application  of  the  cau- 
tery and  the  support  of  intersecting  strips  of  adhesive  plaster, 
covering  a  wide  area,  will  often  relieve  the  pain.  Later,  massage, 
electricity,  and  the  like  are  of  service. 

In  milder  cases,  in  which  the  symptoms  may  be  dependent 
on  a  general  descent  of  the  abdominal  and  pelvic  organs,  an  ab- 
dominal belt  will  afford  great  relief. 


The  Neurotic  Spine. 

The  "neurotic"  spine  is  much  more  common  in  adolescence 
and  in  adult  life  than  in  childhood,  and  the  subjects,  usually 
females,  are  often  of  a  nervous  or  neurasthenic  type.  In  certain 
instances  the  symptoms  appear  to  be  induced  by  injury,  and  in 
others  by  worry  or  overwork. 

Symptoms. — The  patient  usually  complains  of  a  dull  pain  in 
the  back  of  the  neck,  or  in  the  lumbar  or  sacral  region,  of  a  con- 
stant tired  feeling,  and,  not  infrequently,  of  sharp  neuralgic  pain 
localized  about  a  certain  point  in  the  spine,  often  the  vertebra 
prominens.  The  contour  of  the  spine  may  be  normal,  but  most 
often  there  is  a  lessening  of  the  lumbar  lordosis  a  backward 
inclination  of  the  body  and  a  forward  droop  of  the  head,  an  atti- 
tude that  signifies  muscular  weakness  and  strain  upon  the  liga- 
ments. One  of  the  common  symptoms  of  the  neurotic  spine  is 
extreme  local  tenderness,  or  hypera\sthesia,  of  the  skin  at  certam 
points  along  the  spinous  processes.  Thus,  if  one  passes  the  finger 
gently  along  the  spine  the  patient  will  often  shrink  or  cry  out 
because  of  the  pain.  As  a  rule,  there  is  no  limitation  of  motion 
or  muscular  spasm.  The  pain  is  local,  not  referred  to  the  ter- 
minations of  the  nerves;  in  fact,  the  symptoms  are  in  great  part 
subjective  and  irregular  in  character,  as  contrasted  with  those 
of  actual  disease,  which  are  objective  and  well-defined. 


144:  OB THOPEDIC  SUROEB  Y 

Treatment. — The  treatment  of  the  neurotic  spine  must  be 
general  in  character,  as  indicated  by  the  condition  of  the  patient. 
Locally,  a  light  back  brace  or  a  long  corset,  reinforced  if  neces- 
sary by  light  steel  back  bars,  adds  greatly  to  the  comfort  of  the 
patient.  The  application  of  the  cautery  is  particularly  efficacious 
in  relieving  the  local  sensitiveness.     Massage  and  light  exercises 

Fig.  84 


The  neurotic  spine.     Characteristic  attitude. 

may  be  employed  in_the  later  treatment.  Weak  feet  are  often 
as.sociated  with  this  condition.  In  such  instances  appropriate 
treatment  often  induces  a  marked  improvement  in  the  general 
condition. 

The  Hysterical  Spine. 

The  hysterical  spine  is  considered  usually  as  synonymous  with 
the  neurotic  spine,  but  as  there  are  many  individuals  who  suffer 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      145 

from  sensitive  spines  who  are  not  hysterical,  it  would  seem  proper 
to  limit  the  latter  term  to  the  hysterical  class. 

Symptoms.— The  local  symptoms  do  not  differ  particularly 
from  those  of  the  neurotic  spine  except  that  in  certain  instances 
actual  deformity  may  be  present.  This  is  usually  an  exaggerated 
lateral  distortion,  most  marked  in  the  lumbar  region.  Like  hys- 
terical distortions  elsewhere,  it  may  follow  injury,  and  it  may 
be  claimed  that  this  injury  was  the  direct  cause  of  the  deformity. 
Except,  however,  as  possible  cause  of  the  appearance  of  a  par- 
ticular manifestation  of  the  mental  condition,  it  is  evident  that 
no  form  of  injury  could  explain  the  symptoms  or  the  deformity. 

Treatment.— The  local  treatment  is  similar  to  that  of  the 
neurotic  spine. 

Deformity  Secondary  to  Sciatica. 

Synonym. — Sciatic  scoliosis. 

Chronic  sciatica  often  induces  a  change  in  the  attitude  and  con- 
tour of  the  spine  that  may  become  a  permanent  deformity  if  its 
cause  persists.  As  a  rule,  the  patient  habitually  inclines  the 
body  away  from  the  painful  part  in  order  to  relieve  it  from  weight 
and  l)ends  the  body  slightly  forward  and  abducts  the  limb  to 
relax  the  tension  on  the  sensitive  nerve  or  plexus  of  nerves.  Thus, 
the  pelvis  on  the  affected  side  projects,  there  is  a  lateral  lumbar 
convexity  toward  the  opposite  side,  and  often  the  normal  lumbar 
lordosis  is  lessened  or  lost,  so  that  the  final  result  may  be  a  per- 
sistent lateral  curvature,  together  with  a  change  in  the  antero- 
posterior contour  of  the  spine.  If  the  deformity  persists  a  second 
compensatory  curve  may  appear  (Fig  85).  If  the  sciatica  is  a 
symptom  of  a  more  widespread  neuritis,  muscular  weakness 
and  muscular  spasm  may  cause  variations  in  the  typical  attitude, 
the  muscles  of  one  side  being  persistently  contracted. 

It  must  })e  borne  in  mind  that  disease  of  the  lumbar  spine, 
particularly  at  the  lumbosacral  articulation,  may  induce  similar 
distortion  of  the  spine  accompanied  by  pain  in  the  limbs.  Also 
that  disease  of  the  pelvic  bones  or  joints,  or  of  the  adjacent 
organs  or  parts,  may  set  up  sciatica;  thus,  the  cause  of  pain 
should  be  carefully  sought  for. 

Aside  from  the  direct  treatment  of  sciatica,  support  for  the 
spine,  preferably  a  light  corset,  may  be  indicated  if  motion  aggra- 
vates the  pain.     If  the  deformity  persists  it  should  be  corrected 

gradually,  by  repeated  applications  of  a  plaster  jacket. 

10 


146  OB THOPEDIC  SURGEB Y 

Neuritis  in  other  regions  of  the  spine  may  cause  symptoms  of 
reflected  pain  and  local  sensitiveness.  These  symptoms  are 
increased  by  motion,  and  a  certain  amount  of  local  deformity, 
similar  in  character  to  that  due  to  sciatica,  may  be  present. 

The  treatment  is  similar  to  that  indicated  in  the  former  affection. 


Sacroiliac  Disease. 

Tuberculous  disease  of  the  sacroiliac  articulation  is  a  rare 
affection  and  extremely  so  in  childhood. 

Symptoms. — The  symptoms  are  pain,  weakness,  limp,  and 
change  in  attitude.  The  pain  is  referred  to  the  side  of  the  pelvis 
or  radiates  over  the  buttock  or  thigh.  It  is  increased  by  jars, 
by  turning  the  body  suddenly,  sometunes  by  coughing  or  laugh- 
ing; and  a  peculiar  feeling  of  insecurity  and  vv^eakness  is  some- 
times complained  of.  As  a  rule,  the  body  is  inclined  toward  the 
sound  limb;  thus  the  pelvis  is  lowered  on  the  affected  side  and 
the  leg  seems  longer  than  its  fellow.  In  the  early  stage  of  the 
disease  there  is  no  deformity  of  the  limb,  but  if  a  pelvic  abscess 
forms,  the  thigh  may  become  flexed.  Locally,  there  may  be  sen- 
sitiveness to  pressure  over  the  articulation,  and  swelling  in  the 
neighborhood  of  the  disease,  although  this  is  usually  a  late  symp- 
tom. Pain  is  induced  by  lateral  pressure  on  the  pelvis  or  by 
any  manipulation  that  disturV)S  the  articulation. 

Abscess  finally  forms  in  the  majority  of  cases.  It  may  be 
ex-trapelvic  or  intrapelvic.  The  intrapelvic  abscess  may  present 
above  the  crest  of  the  ilium,  or  the  pus  may  pass  through  the 
sciatic  notch,  or  appear  in  the  ischiorectal  fossa,  or  break  into 
the  rectum. 

Diagnosis. — Sacroiliac  disease  may  be  mistaken  for  sciatica 
or  for  disease  of  the  hif  or  spine.  The  freedom  of  motion  and 
the  absence  of  muscular  spasm  when  the  pelvis  is  fixed,  if  the 
examination  is  carefully  conducted,  should  exclude  both  the  one 
and  the  other,  although  the  pain  on  lateral  pressure,  which  is 
described  as  the  most  characteristic  symptom,  may  be  simulated 
closely  by  primary  acetabular  disease.  The  attitude  is  similar 
to  that  of  sciatica,  but  the  symptoms  of  local  sensitiveness  to 
jars  and  to  manipulation  are  much  more  marked. 

Prognosis. — According  to  the  statistics  the  prognosis  is  very 
unfavorable,  probably  because  the  majority  of  the  reported  cases 
were  in  adults  and  were  complicated  by  infected  ajid  burrowing 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  SPINE      147 

abscesses,  which  constitute  the  chief  danger  of  this  fonn  of  tu- 
berculous disease. 

Treatment. — The   local   treatment   consists  in  protecting   the 
diseased   parts  from  injury   and   in   the   radical   removal   of  the 


Fig.  85 


Fig.  86 


Deformity  causetl  by  persistent  sciatica  of 
the  right  side.  This  attitude  is  similar  to  that 
symptomatic  of  sacroiliac  disease. 


Sacroiliac  disea.se  in  a  child,  showing 
the  extra  pelvic  abscess  above  the  dis- 
eased articulation. 


disease  if  it  has  reached  the  stage  of  abscess  formation,  if  this  be 
feasible. 

In  the  ambulatory  treatment  of  advanced  cases  a  plaster  spica 
bandage  or  a  double  Thomas  hip  brace  may  be  indicated,  but  in 


148  ORTHOPEDIC  SURGERY 

most  instances  a  broad,  strong  pelvic  girdle,  which  may  be  drawn 
tightly  about  the  pehas,  will  be  most  efficient.  As  a  temporary 
support  wide  encircling  bands  of  adhesive  plaster  may  be  used. 
If  motion  of  the  spine  causes  discomfort  a  spinal  brace  provided 
with  a  wide  pelvic  band  of  thin  steel  that  may  clasp  the  pelvis 
firmly  is  more  efficacious.  If  the  disease  is  progressive,  rest  in 
bed  will  be  necessary. 

^Vhen  abscess  is  present  radical  treatment  is  usually  indi- 
cated. The  articulation  should  be  freely  exposed  and  the  dis- 
eased bone  should  be  entirely  removed,  if  possible.  Intrapelvic 
abscess  should  be  drained  through  a  direct  communication,  if 
possible,  in  order  to  check  the  tendency  toward  burrowing. 


Injury  of  the  Sacroiliac  Articulation. 

In  some  instances  the  symptoms  of  sacroiliac  disease  are 
apparently  due  directly  to  falls  on  the  buttock  or  pelvis  or  to 
strains.  In  such  cases  there  may  be  an  actual  injury  or  displace- 
ment at  the  articulation.  This  is  particularly  likely  to  occur  if 
the  articulations  are  relaxed  as  the  effect  of  pregnancy.  The 
treatment  has  been  indicated  already.     The  prognosis  is  favorable. 


CHAPTER    III. 

LATERAL  CURVATURE   OF  THE   SPINE. 

Synonyms. — Rotary  lateral  curvature — scoliosis. 

Lateral  curvature  of  the  spine  is  an  habitual  or  fixed  deformity 
in  wliich  the  spine  is  deviated  in  whole  or  part  to  one  or  the  other 
side  of  the  median  line. 

By  limiting  the  term. to  habitual  deformity  one  excludes  simple 
postural  inclination  of  the  spine.  For  example,  if  one  leg  were 
considerably  shorter  than  the  other  the  pelvis  would  be  tilted 
downward  on  the  short  side,  and  there  would  be  a  compensatory 
curvature  of  the  spine  in  the  erect  attitude,  which  would  disap- 
pear in  the  sitting  posture.  This  accommodative  or  compensa- 
tory inclination,  and  those  of  similar  origin,  are  not,  in  the  proper 
sense,  lateral  curvatures. 

In  persistent  lateral  curvature  the  weight  supporting  part  of 
the  column  is  more  distorted  than  are  the  spinous  processes, 
because  lateral  bending  is  always  accompanied  by  a  certain 
degree  of  twisting  or  rotation  of  the  vertebral  bodies.  This  rota- 
tion is  in  the  direction  of  the  convexity  of  the  curve,  and,  as  the 
bodies  rotate,  the  spinous  processes  are  carried  in  the  reverse 
direction.  Thus  it  is  that  well-marked  rotation  may  be  present, 
although  there  may  be  comparatively  little  lateral  deviation  of 
the  line  of  the  spinous  processes. 

In  the  physiological  movements  of  the  spine,  simple,  direct 
lateral  motion — that  is,  motion  allowed  by  the  small  joints  of  the 
spine  and  by  the  lateral  compression  of  the  intervertebral  disks 
— is  very  limited.  The  larger  movements  nnist  be  accompanied 
by  rotation  of  the  vertebral  Ixxlies  by  which  this  continuous  or 
solid  part  of  the  colunni  is,  as  it  were,  forced  from  the  shortened 
toward  the  lengthened  side  (Fig.  87).  When,  for  example,  one 
flexes  the  head  to  bring  the  ear  as  near  the  sl.oulder  as  is  ])()ssi))le 
there  is  necessarily  an  accompanying  rotation  of  the  vhin  in  the 
opposite  direction  caused  by  the  twisting  of  the  bodies  of  the 
cervical  vertebra?  toward  the  convexity  of  the  curve. 

In  the  simple  accommodative  lateral  inclination  of  the  body  to 
one  side  or  the  other,  the  change  in  contour  of  the  s])inc  wculd  be 


150 


OR  TH  OPE  Die  SURGERY 


more  noticeable  if  it  could  be  observed  from  the  front  rather  than 
from  the  back,  and  as  lateral  curvature  is  simply  a  persistent 
de\-iation  of  the  spine,  one  of  the  so-called  static  deformities  which 
are  directly  induced  or  exaggerated  by  superincumbent  weight, 
it  may  be  assumed  that  rotation  of  the  vertebral  bodies  precedes 
the  lateral  distortion  that  first  attracts  attention. 

It  is  probable,  also,  that  slight  rotation  may  not  cause  at  once 
an  appreciable  degree  of  external  distortion,  and,  although  marked 
lateral  curvature  is  necessarily  combined  mth  rotation,  yet  it  is 

'Fig.  87 


Physiological    rotation  acooriipanyjiit;   flexion  and  lateral  inolination  of    the  trunk  in 
the  normal  subject. 

possil)le  that  a  slight  degree  of  direct  lateral  deviation  may  exist 
unaccompanied  by  appreciable  rotation.  Rotation  is  usually 
understood  to  imply  fixed  deformity,  while  lateral  deviation  may 
mean  simply  an  habitual  posture;  but  it  is  far  simpler  to  consider 
the  two  as  parts  of  one  distortion.  The  important  distinction  is 
between  habitual  deformify,  implying  the  habitual  assumption 
of  an  improper  attitude  in  which  the  accommodative  changes  in 
structure  Yiiivc  not  advanced  siifliciently  to  prevent  vohmtary  or 


LATERAL  CURVATURE  OF  THE  SPINE  151 

passive  correction,  and  fixed  deformity  in  wliich  the  changes  in 
the  bones  and  other  tissues  have  made  cure  difficult  or  impossible. 
The  evidence  of  fixed  deformity  is  rotation  that  persists  after  the 
lateral  deviation  has  been  overcome.  It  persists  because  the 
early  and  important  changes  must  take  place  in  tl:e  bodies  of  the 
vertebrae  upon  which  the  weight  falls,  but  there  is  no  reason  to 
believe  that  habitual  rotation  as  an  accompaniment  of  habitual 
lateral  curvature  may  not  be  corrected  if  it  be  treated  at  th.e 
proper  time. 

The  necessity  for  dividing  the  weight  about  the  centre  of  gra\ity 
in  order  to  balance  the  body  in  the  upright  position  accounts 
for  the  distribution  and  effects  of  lateral  curvature.  As  the  normal 
contour  of  the  spine  is  the  necessary  result  of  static  conditions, 
a  change  from  this  normal  relation  of  one  part  necessitates  a 
corresponding  change  elsewhere.  If  there  is  a  primary  lumbar 
curvature  and  rotation  to  the  left  in  the  lower  region,  a  corre- 
sponding lateral  deviation  and  rotation  to  the  right  in  the  region 
above  usually  develops,  thus  restoring  the  balance  of  the  body. 
This  explains  the  ordinary  S-shaped  or  double  curve  of  scoliosis, 
one  of  which  is  primary  and  the  other  secondary.  These  curves 
may  divide  the  spine  equally  or  there  may  be  a  long  and  a  short 
one,  and  occasionally  three  distinct  curves  may  be  present.  If 
the  primary  curve  is  sHght,  the  secondary  curvature  will  be  slight 
also,  and  the  primary  curve  persists  doubtless  for  a  time  before 
the  secondary  distortion  appears.  In  some  instances  the  spine 
may  be  bent  laterally  into  one  long  curve,  "total  scoliosis"  (Fig.  <SS). 
This  is  probably,  in  many  instances  at  least,  the  initial  stage  of  the 
ordinary  type  of  scoliosis,  the  long  curve  being  afterward  divided, 
although  it  may  persist.  In  childhood  total  scoliosis  is  often 
combined  with  general  posterior  curvature,  and  it  is  peculiar 
in  that  the  torsion  of  the  vertebrae  may  be  toward  the  concave 
instead  of  the  convex  side,  the  torsion  representing  probably 
the  early  stages  of  the  secondary  or  compensatory  curve. 

It  has  been  stated  that  deformity  of  one  part  of  the  spine  is 
usually  balanced  l)y  deformity  of  anotlier.  '^l^'his  enables  the 
trunk  to  hold  the  erect  posture,  and  it  restores  its  general  sym- 
metry. If,  however,  a  long  lateral  or  long  posteri(M'  curvature 
persists,  the  weight  can  be  balanced  only  by  swa^n'ng  tl  e  entire 
body  on  the  pelvis,  in  the  direction  opposed  to  the  distortion. 
This  restores  the  balance,  but  not  the  symmetry  (Fig.  102). 

Rotation  and  Lateral  Deviation. — Fixed  rotation  of  the  spine 
carries  with  it,  of  course,  all  tl.e  parts   that  are  attached  to  it. 


152 


OB THOPEDIC  SURGERY 

Fig.  88 


Congenital  total  scoliosis.     Compare  with  Fiff.  81. 


Fig.  89 


Congenital  total  scolio.HJa.     The  rotation  is  much  greater  than  I  hi;  lateral  deviation. 
Compare  with  Fig.  88. 


LATERAL  CURVATURE  OF  THE  SPINE 


153 


When  the  patient  stands  in  the  erect  attitude  the  simple  lateral 
distortion  is  most  noticeable  (Fig.  88),  but  when  the  body  is  bent 
forward  the  twist  of  the  trunk  becomes  the  prominent  deformity 
(Fig.  89).  If  the  thoracic  region  is  involved,  the  ribs  on  the 
side  toward  which  the  spine  is  rotated  project  backward,  and  on 

Fig.  90 


Primary    lumbar  curvature  to  the  left.     A  "flat  back"  iiuirkcil  rutaliun  with  but    .sli;;ht 

lateral   curvature. 


the  other  side  of  the  spine  there  is  an  abnormal  flatness  or 
depression.  The  projection  of  the  ribs  due  to  the  twisting  of  the 
thorax  is  far  more  noticeable  than  is  the  simple  twisting  of  the 
free  portions  of  the  spine  in  the  neck  or  loins;  and  in  these 
regions  the  projecting  transverse  processes  covered  by  the  thick 
layers  of  muscles,  yet  unaccompanied  by  marked  lateral  deviation, 


154 


OR  THOPEDIG  SUBGEBY 


may  cause  mistakes  in  diagnosis.  In  the  cervical  region,  for 
example,  as  an  accompaniment  of  acute  torticollis,  the  projecticn 
may  be  mistaken  for  abscess;  and  in  tl  e  lumbar  region  it  has 
been  mistaken  for  a  new-growth  attached  to  the  spine. 

Although  persistent  lateral  curvature  of  the  spine  is  always 
accompanied  by  rotation,  the  degree  of  rotation  does  not  always 
correspond  to"  that  of  the  more  e^^dent  lateral  de\'iation.  In  tl  e 
instance  cited,  rotation  in  the  lumbar  region,  so  extreme  as  to 


Fig.  91 


Scoliosis  with  marked  ijot-lerior  deformity. 

siuiuhite  an  abncnual  growth,  may  exist  with  but  shght  lateral 
distortion;  while  in  other  cases  the  body  appears  to  be  greatly 
displaced  to  one  side,  although  there  may  })e  comparatively  little 
fixed  rotation.  Again,  as  lias  been  stated,  the  lateral  deviation 
of  the  trunk  is  usually  more  noticeable  than  the  rotation,  which 
in  the  sliglitest  grades  of  deforinity  is  only  made  ap])arent  when 
the  patient  is  bent  forward  so  that  the  back  may  be  inspected  in 


LATERAL  CURVATURE  OF  THE  SPINE  155 

the  horizontal  position.  It  may  be  noted,  also,  that  the  degree 
of  habitual  lateral  distortion  of  the  body  does  not  correspond  to 
the  degree  of  fixed  distortion.  One  individual,  by  voluntary 
effort,  may  practically  conceal  advanced  deformity,  while  another 
who  makes  no  effort  to  correct  the  improper  posture  appears  to 
be  greatly  distorted,  although  the  fixed  changes  may  be  very 
slight. 

The  effects  of  the  deformity,  Ijoth  general  and  local,  depend 
upon  its  situation  and  its  degree.  In  one  instance  it  may  be  so 
slight  as  to  pass  unnoticed,  and  in  another  the  distortion  may 
ec|ual  that  of  Pott's  disease  (Fig.  91).  If  compensation  is  per- 
fect— that  is,  if  the  deformity  is  equally  distributed  on  either 
side  of  the  median  line — the  general  symmetry  of  the  body  may 
be  but  slightly  disturbed.  Or,  if  the  compensation  for  the  pri- 
mary deformity  of  the  lumbar  region  is  distributed  throughout 
the  remainder  of  the  spine,  noticeable  distortion  may  be  insig- 
nificant, but  when  there  is  a  long  curve  involving  the  thoracic 
region  the  lateral  and  posterior  displacement  cannot  be  concealed 
(Fig.  92). 

Changes  in  the  Anteroposterior  Contour.  —  Lateral  distortion 
involves  also  secondary  changes  in  the  anteroposterior  outline 
of  the  spine.  Wlien  the  distortion  is  marked  the  stature  is 
shortened,  especially  when  the  anteroposterior  curves  are  increased 
in  addition  to  the  lateral  de\Tation.  In  general,  one  may  recog- 
nize two  types  of  lateral  curvature:  one  in  which  the  back  is 
flatter  than  normal,  in  which  the  anteroposterior  curves  are 
diminished,  and  another  in  which  they  are  increased.  It  has 
been  stated  in  the  account  of  Pott's  disease  that  deformity 
in  one  segment  of  the  spine  always  caused  a  change  in  the 
contour  of  the  spine  as  a  whole,  that  an  obliteration  or  a  lessen- 
ing of  the  concavity  of  the  lumbar  region  was  accompanied  by  a 
corresponding  flattening  of  the  normal  dorsal  kyphosis.  On  the 
other  hand,  that  an  increase  in  the  backward  projection  of  the 
dorsal  region  caused  an  increase  in  the  concavity  of  the  parts  below. 
The  variations  in  the  anteroposterior  contour  of  the  spine  in 
lateral  curvature  may  be  accounted  for  in  the  same  manner.  In 
the  one  instance  the  primary  deformity  is  of  the  lower  region, 
and  with  its  accompanying  backward  twist  of  thiC  vertebral  bodies 
it  lessens  the  lumbar  lordosis  and  tends  to  flatten  the  back  (Fig. 
90).  If,  on  the  other  hand,  the  deformity  begins  in  the  thoracic 
region,  the  primary  effect  is  to  increase  the  backward  projection, 
and  this  in  turn  tends  to  exaggerate  the  luml)ar  lordosis  (Fig.  19). 


156 


ORTHOPEDIC  SURGERY 


Thus,  the  shortening  of  the  trunk  in  the  kunbar  region  caused 
by  the  lateral  de\iation  may  be  to  a  certain  extent  compensated 
in  the  first  instance,  while  in  the  other  both  the  primary  and 
secondary  distortions  tend  to  reduce  the  height. 

The  "  High"  Shoulder  and  the  "  High"  Hip. — Wlien  the  convex- 
ity of  the  primary  curve  is,  for  example,  to  the  left  in  the  lumbar 
region  the  trunk  is  displaced  somewhat  to"*  the  left,  consequendy 


Fig.  9:> 


Scoliosis  witli  extreme  lateral  deviation. 


the  right  "liip"  becomes  abnormally  prominent,  a,  prominence 
that  is  usually  mistaken  for  an  elevation,  and  in  c(mipensation 
for  the  (lisj)liicernent  Ix'low  there  is  a  corresponding  twist  in  the 
opposite  direction  above.  'J'he  spine  bending,  and  at  the  same 
time  rotating  toward  the  right,  carrying  with  it  the  ril)S,  raises  the 
shoulder  and  makes  the  scaj)Mhi  prominent.  Thus  it  is  that  in 
the  ordinary  S-sliaped  curve  the  high  shoulder  and  the  projecting 


LA  TERAL  C  UE  VA  T  URE  OF  THE  SPINE  ]  5  7 

hip  appear  usually  upon  the  same  side  of  the  body.  But  in  less 
regular  varieties  of  distortion,  when,  for  example,  there  is  marked 
general  lateral  deviation  of  the  trunk  as  a  whole,  the  high  shoulder 
may  be  on  the  opposite  side  (Fig.  92).  It  is  prol)a])le  that  the 
primary  curvature  is  in  most  instances  to  the  left  in  the  lumbar 
region,  the  compensation  to  the  right  appearing  at  a  later  time. 
This  is  certainly  true  of  the  milder  types  of  postural  curva- 
ture. 

Pathology. — Lateral  curvature  of  the  spine  is  a  deformity, 
not  a  disease,  nor  is  it  in  the  ordinary  cases  an  efi'ect  of  disease. 
For  this  reason  the  description  of  the  pathology  which  is  merely 
a  more  detailed  account  of  the  deformity  and  of  its  secondary 
effects  upon  the  trunk  and  its  contents  may,  for  convenience, 
precede  the  discussion  of  the  etiology. 

In  such  a  description  one  must  consider  the  spine  as  a  whole,  a 
column  bent  and  twisted,  in  which  each  component  segment  bears 
its  share  of  the  general  distortion.  The  vertebra  at  the  apex 
of  each  curve  shows  the  greatest  change.  If  the  rotation 
and  lateral  deviation  is  to  the  right  the  vertebral  body  is 
somewhat  wedge-shaped,  the  apex  of  the  wedge  being  directed 
backward  and  to  the  left.  Its  lateral  diameter  is  increased 
and  the  superior  and  inferior  margins  at  the  narrow  side  pro- 
ject, increasing  its  lateral  concavity  (Fig.  96).  Similar  accom- 
modative changes,  although  less  marked,  are  to  be  found  in  the 
articular  processes  and  in  the  laminae;  in  fact,  all  the  parts  on 
the  concave  side  are  broadened,  shortened,  and  lessened  in  vertical 
diameter  as  compared  with  those  on  the  convex  side  of  the  spine. 
These  changes  affect  the  shape  of  the  neural  canal,  which  becomes 
somewhat  ovoid  in  outline,  the  base  being  directed  toward  the 
convexity  of  the  curve  (Fig.  97).  In  the  vertebra*,  included  in 
the  compensatory  curvature,  the  deformities  are  reversed,  and 
the  intermediate  segments  show  ti.e  transitional  chanjres  between 
the  two  extremes.  The  intervertebral  disks  become  wetige-shaped 
also,  and  atrophied  on  the  shortened  side,  the  changes  in  these 
softer  t'ssues  preceding,  undoubtedly,  those  in  the  bones.  The 
articulations  of  the  vertebnv  become  changed  in  shape  and  posi- 
tion in  the  general  adaptation  to  the  deformity  and  the  ligaments 
are  shortened  or  lentrthened  accordino:  to  their  relation  to  the 
distortion. 

On  section  the  internal  structure  of  the  vertebra*  shows  the' 
same  adaptive  changes  that  are  e\ident  on  the  exterior.     In  the 
narrowed  parts  of  the  bones  that  bear  the  weight  the  tissue  is 


158 


OR THOPEDIC  SUBGEBY 


thick  and  compact,  and  on  the  opposite  side  it  is  attenuated  and 
atrophied. 

The  mobihty  of  the  spine  is  lessened  by  these  changes  in  its 
shape  and  structure,  primarily  by  the  distortion,  secondarily  by  the 


shortening  oi  the  tissues  on  the  concave  side,  l)y  the  irregularities 
of  the  vertebral  bodies,  by  the  interference  of  the  newly  formed 
or  transformed  bone  which  is  tlirown  out  about  the  margins  of 
the  vertebrae  and  tlie  articular  processes,  and  by  ossification  of 


LATERAL  CURVATURE  OF  THE  SPINE 


159 


the  periosteum  and  ligamentous  coverings  of  the  adjacent  bones. 
Thus,  in  fixed  deformity  there  may  be,  at  the  points  of  greatest 
distortion,  practical  anchylosis.  The  muscles  of  the  back,  both 
intrinsic  and  extrinsic,  undergo  adaptative  changes,  and,  as  a 
rule,  they  are  relatively  weak. 

The  distortion  of  the  vertebral  column  causes,  of  course,  a  dis- 
tortion of  the  trunk  of  which  it  is  the  support,  and  this  distortion 
is  of  the  greatest  importance  in  its  effect  upon  the  thorax.  The 
deformity  of  the  thorax  is  somewhat  difficult  to  describe,  because 


Fig.  96 


Scoliotic  vertebrae.     (Hoffa.) 

the  distortion  of  the  dorsal  vertebrae  does  not  affect  the  thorax 
equally;  thus,  it  is  not  twisted  as  a  whole,  nor  flexed  as  a  whole. 
The  nature  of  the  deformity  may  be  better  understood  by  consid- 
ering the  sternum  as  a  fixed  point;  this,  as  a  matter  of  fact,  it  is, 
as  compared  with  the  spine.  At  the  apex  of  the  convexity  of 
the  curve  the  ribs  are  drawn  sharply  backward;  their  angles 
project  by  the  side  of  and  beyond  the  spinous  processes,  some- 
times covering  and  concealing  them,  and  the  lateral  convexity 
of  the  chest  is  diminished  or  lost.  On  the  opposite  side  the 
back  is  broadened  and    flattened.     The    eft'cct    of    the    rotation 


160 


ORTHOPEDIC  SURGERY. 


is  to  diminish  tlie  capacity  of  the  chest  on  the  convex  side 
and  to  increase  that  of  the  concave  side  (Fig.  98).  On  the 
convex  side  the  ribs  are  elevated  and  their  inchnation  is  in- 
creased. On  the  concave  side  the  intercostal  spaces  are  narrowed 
and  the  inclination  is  lessened  (Fig.  95).  The  anteroposterior 
diameter  of  the  chest  is  increased  or  diminished  according;  to 
the  change  in  the  anteroposterior  contour  of  the  spine.  If 
the  dorsal  kyphosis  is  exaggerated  the  effect  is  to  deepen  the 
chest  (Fig.  91);  if  it  is  diminished,  the  diameter  of  the  thorax 
is  correspondingly  lessened. 

The  cervical  section  of  the  spine  is  not  often  involved,  to  a 
marked  degree  at  least,  in  the  lateral  deformity.     But  in  extreme 


Fig.  97 


Change  in  tfhape  of  the  spinal  canal,  Ijioatler  on  the  c(jn\'ex  side.      CHoffa.) 


cases,  in  wliicJi  the  neck  and  head  are  habitually  distorted,  the 
skull  may  show  accommodative  changes  similar  to  those  in- 
duced by  persistent    torticollis. 

At  the  other  extremity  of  the  spine  the  pelvis  is  not,  as  a  rule, 
markedly  deformed.  In  some  instances  the  oblique  diameter, 
ojjposed  to  the  convexity  of  the  lumbar  deformity,  may  be  in- 
creased, and  if  the  lateral  deviation  of  the  lumbar  spine  is 
extreme  the  pelvis  may  be  so  tilted  that  the  limb  on  the  elevated 
side  becomes  practically  shorter  than  its  fellow. 

In  changes  that  have  been  described  the  contents  of  the  trunk 


LATERAL  CURVATURE  OF  THE  SPINE 


161 


participate  to  a  greater  or  less  degree.  Tlie  lung  on  the  convex 
side  is  more  or  less  compressed  by  the  distorted  ribs  and  by  the 
displaced  vertebral  bodies.  The  heart  may  be  displaced  later- 
ally or  in  other  directions  according  to  the  position  of  the  de- 
formity, and  the  bloodvessels  are  changed  in  direction,  and,  it 
may  be,  altered  in  calibre.  In  those  cases  in  which  the  thorax 
is  markedly  distorted  the  effect  is  similar  to  that  of  the  deformity 
of  Pott's  disease;  respiration  is  shallow  and  rapid,  the  pulse-rate  is 
usually  increased,  and  other  evidences  of  interference  with  the 
vital  functions  may  be  apparent.  The  abdominal  organs  are 
affected,  doubtless,  in  a  similar  manner,  but  symptoms  due 
to  this  cause  are  not,  as   a  rule,   as  clearly  marked. 


Fig.  98 


Deformity  of  the  thorax  in  scoliosis.     (Hoffa.) 

Bachmann^  investigated  the  secondarv  changes  induced  1)V 
severe  scoliotic  deformity  coming  under  his  observation  in  the 
pathological  institute  of  Breslau.  In  91. .3  per  cent,  of  the  sul)- 
jects  defect  or  disease  of  the  circulatory  apparatus,  antl  in  99.1 
per  cent,  of  the  respiratory  organs  was  observed. 

Etiology.  Relative  Frequency. — lyateral  curvature  of  the  spine 
is  one  of  the  most  common  of  deformities.  In  a  period  of  fifteen 
years— 1885  to  1899 — 3252  cases  were  recorded  in  the  out-patient 
department  of  the  Hospital  for  Ruptured  and  Crijipled,  a  number 
only  exceeded  by  that  of  bow-legs,  of  which  5030  cases  were 
treated  during  the  same  period. 


'   Bachmaim,  Die  VeriintleruiiKeii  an  den   inneren    Organen  bei  hochgrailigen  Skoliosen 
\\ml  Kyphoskoliosen,   Bibliotheca  Medica,   1900,  Ab.   D.   1,  H.  4. 

u 


162  ORTHOPEDIC  SVBGEBY 

The  relative  frequency  of  lateral  curvature  among  children 
in  general  is  illustrated  by  the  statistics  of  Drachmann,  who 
found  among  28,175  school-children  (16,789  boys,  11,386  girls) 
of  Denmark  368  cases  of  scoliosis  (1.3  per  cent.),  and  those  of 
Scholder,  Werth,  and  Combe,^  who  found  571  cases  of  lateral 
curvature  among  2314  school-children  of  Switzerland  (24.6  per 
cent.),  a  discrepancy  that  is  somewhat  difficult  to  explain. 

Sex. — Lateral  curvature  of  the  spine  is  far  more  common 
among  females  than  males.  Of  the  3252  cases  referred  to,  2554 
(78.5  per  cent.)  were  in  females  and  698  (21.4  per  cent.)  were  in 
males. 

The  lowest  percentage  of  males  in  any  one  of  the  fifteen  years 
was  14.8,  the  highest  25.1.  This  proportion  of  one  male  to  four 
females  is  somewhat  larger  than  in  the  smaller  groups  of  cases 
reported  by  other  observers. 

The  unequal  distribution  of  the  deformity  between  the  sexes 
is  of  great  interest  as  bearing  on  the  question  of  etiology;  espe- 
cially so  as  in  the  cases  that  develop  in  early  childhood,  sex  ap- 
pears to  exercise  practically  no  influence.  It  has  been  suggested 
that  curvature  of  the  spine  in  a  girl  is  looked  upon  with  more 
solicitude  by  the  mother  than  is  the  same  deformity  in  a  boy,  there- 
fore, more  girls  are  brought  for  treatment.  There  may  be  some 
basis  for  this  argument,  for  it  is  certain  that  distortions  of  the 
lower  extremities  are  considered  of  greater  importance  in  male 
than  in  female  children,  because  of  the  concealment  to  be  afforded 
by  the  skirts,  if  the  deformity  is  not  outgrown.  But  granting 
that  statistics  are  somewhat  unreliable,  there  can  be  no  doubt 
but  that  this  deformity  is  far  more  common  among  girls  than 
boys  and  that  the  disproportion  may  be  explained,  in  great  part 
at  least,  by  the  differences  in  dress  and  in  manner  of  life. 

Age. — One  thousand  two  hundred  and  ninety-nine  (39.9  per 
cent.)  of  the  3252  patients  referred  to  were  less  than  fourteen 
years  of  age;  1576  (48.4  per  cent.)  were  between  fourteen  and 
twenty-one;  377  (11.6  per  cent.)  were  more  than  twenty-one 
years  of  age.  These  statistics  simply  show  the  age  of  the  patients 
at  the  time  treatment  was  sought,  and  they  are  of  little  value 
as  an  indication  of  the  age  at  which  deformity  might  have  been 
detected  had  it  been  looked  for. 

There  is  no  reason  to  suppose  that  lateral  curvature  of  the 
spine  differs  in  its  etiology  from  similar  deformities  of  other 
parts     except  in    so    far   as   each   region   of  the  body  is   more 

'  JOxtrait  dcs  AniialH  WuiHseH  d'ily(;ieiic  Scolaire,  1901. 


LATERAL    CURVATURE    OF  THE  SPINE 


163 


or   less    susceptible   to   deforming   influences    at   one    time    tlian 
another. 

For  example,  rhachitic  deformities  of  the  upper  extremities 
practically  never  develop  except  in  infancy,  and  they  begin  to 
correct  themselves  when  the  erect  posture  is  assumed  or  at  the 
very  time  when  distortions  of  similar  origin  of  the  lower  extrem- 
ities appear  or  increase.  Wlien  deformities  of  this  class,  whether 
of  the  spine  or  limbs,  appear  in  later  childhood  or  adolescence  it 
may  be  assumed  that,  in  many  instances  at  least,  the  tendency 
toward  the  particular  deformity,  or  even  a  slight  degree  of 
deformity,  was  acquired  at  an  early  age,  that  it  remained  latent 
until  conditions  appeared  which  favored  its  further  develop- 
ment. This  point  is  illustrated  by  the  statistics  of  Eulenburg 
of  1000  cases  of  lateral  curvature  analyzed  with  reference  to  the 
inception  of  the  deformity. 

Between  birth  and  the  sixth  year 78 

"       the  sixth  and  seventh  years 2]  6 

"       the  seventh  and  tenth  years 564 

"       the  tenth  and  fourteenth  years 107 

After  the  fourteenth  year 35 


1000 


It  will  be  noted  that  but  142  (14.2  per  cent.)  of  these  patients 
were  more  than  fourteen  years  of  age  as  contrasted  ^vith  the 
statistics  of  the  Hospital  for  Ruptured  and  Crippled,  in  which 
60   per  cent,   were   beyond  this  age. 

Dr.  Walter  Truslow,  who  for  several  years  had  the  immediate 
charge  of  the  treatment  of  lateral  curvature  at  the  Hospital  for 
Ruptured  and  Crippled,  has  prepared  for  me  statistics  of  a 
number  of  the  cases  which  illustrate  the  same  point. 

A. — Age  when  Treatment  was  Begun. 
Age  when  ezamined. 

4  years 0 


5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

23 

24 

32 


lies. 

Females. 

Total 

0 

1 

0 

1 

1 

2 

4 

6 

4 

11 

4 

8 

2 

9 

3 

13 

16 

3 

16 

19 

4 

28 

32 

5 

25 

30 

3 

21 

24 

8 

14 

22 

2 

6 

8 

1 

2 

3 

0 

1 

1 

0 

1 

1 

0 

4 

4 

0 

1 

1 

0 

1 

1 

0 

1 

1 

44 


157 


201 


164  ORTHOPEDIC  SURGERY 

B. — Age  whex  the  Deformity  avas  Discovered. 

Males.  Females. 

Congenital  (sex  not  stated) 2 

During  infancy  (sex  not  stated'' 19 

Between     3  and     6  years 16  10  6 

6       "  10          " 41  10  31 

"        10       "   13          " 62                6  66 

"       13       "   15          •• 27                3  24 

Over    ,      15  years 14                3  11 

Unknown 20 

201  32  128 

But  44  of  the  ISl  patients  (22.6  per  cent.)  were  more  tban 
thirteen  years  of  age  at  the  time  when  tl  e  deformity  was  first 
noticed,  although  nearly  50  per  cent,  were  older  than  this  when 
treatment  was  applied  for.  In  the  first  table  it  will  be  noted 
that  of  the  38  patients  who  were  ten  years  of  age  or  less,  15,  or 
about  40  per  cent.,  were  males.  Of  25  of  the  37  cases  in 
which  the  deformity  attracted  attention  at  or  before  the  sixth 
year  rhachitis  was  the  apparent  cause. 

Lateral  curvature  of  the  spine  is  one  of  the  penalties  of  the 
erect  posture,  and  the  force  of  gravity  must  be  considered  both 
as  a  predisposing  and  as  an  exciting  cause  of  the  deformity. 
The  more  direct  tendency  of  the  force  of  gravity  is  to  cause 
the  body  to  sink  forward  and  to  increase  the  posterior  curvature 
of  the  spine,  but  whenever  there  is  a  persistent  inclination  of  the 
spine  to  one  or  the  other  side  this  inclination  is  likely  to  be  in- 
creased to  deformity  under  favoring  conditions.  These  favoring 
conditions  would  include  general  weakness  from  any  cause ;  over- 
work that  may  induce  fatigue,  and  all  factors,  mechanical  or 
otherwise,  that  may  add  to  the  difficulty  of  holding  the  trunk 
erect  under  the  pressure  of  the  superincumbent  weight. 

Although  it  is  not  difficult  to  suggest  the  predisposing  causes 
of  lateral  curvature,  it  is  by  no  means  as  easy  to  point  out  the 
direct  cause  of  the  original  inclination  of  the  spine  to  one  or  tl  e 
other  side  of  the  median  line.  In  a  certain  number  of  cases, 
however,  the  relation  between  cause  and  effect  is  sufficiently 
evident,  anrl  these  causes  may  be  enumerated  before  considering 
the  larger  class  in  which  the  etiology  is  more  obscure. 

1.  Lateral   curvature   secondary   to   deformity   of  other   parts. 

2.  Static  or  compensatory  deformity. 

3.  Deformity  seconchiry   to   (h'sease   of  the   nervous   system. 

4.  Deformity  secondary  to  disease  of  the  tlioracic  organs. 

5.  Incidental    deformity. 

0.  Deformity   due   to   occupation. 

7.  Congenita]    (h-Formity. 

8,  Rhachitic   deformity. 


LATERAL   CURVATURE  OF  THE  SPI^'E  165 

1.  Lateral  Curvature  Secondary  to  I)p:FoRMiTy  Else- 
where.— (a)  Lateral  curvature  of  the  spine  may  he  a  compen- 
satory effect  of  torticollis,  either  congenital  or  acquired,  (b)  It 
may  be  induced  by  distortion  of  tlie  lower  extremities.  For 
example,  fixefl  adduction  of  the  tliigh  necessitates  an  upward 
tilting  of  the  pelvis  whenever  the  limb  is  l)rought  into  the 
normal  line,  whether  the  patient  is  standing,  sitting,  or  lying; 
and  this  deformity  when  extreme  may  induce  lateral  curvature 
even  in  bedridden  patients. 

2.  Compensatory  Deformity. — The  same  effect  is  sometimes 
observed  in  certain  instances  of  inecpiality  of  the  length  of  the 
lower  extremities.  In  the  erect  posture  the  pelvis  is  tilted  down- 
ward on  one  side,  and  this  in  turn  necessitating  a  twist  of  the 
spine.  Simple  inequality  of  the  limbs  is  an  occasional  but  not  a 
common  cause  of  fixed  deformity,  because  its  influence  ceases  in 
the  sitting  and  reclining  postures,  and  because  the  inequality  is 
so  often  compensated,  if  it  is  extreme,  by  walking  on  the  toe  or 
by  raising  the  sole  of  the  shoe. 

An  increase  in  the  length  of  a  limb,  such  as  may  be  caused  by 
a  fixed  equinus  of  the  foot,  seems  to  have  more  influence  in  caus- 
ing secondary  deformity  than  does  shortening,  because  no  attempt 
is  made  to  compensate  for  the  inequality. 

3.  Lateral  Curvature  Secondary  to  Paralysls. — Lat- 
eral deformity  of  the  spine  may  be  caused  indirectly  by  a  number 
of  distinct  diseases  of  the  nervous  system,  but  in  this  connection 
only  one  need  be  considered — anterior  poliomyelitis.  This  form 
of  paralysis  may  act  in  several  ways.  It  may  induce  deformity 
by  distortion  of  a  lower  extremity  or  by  inequality  in  the  length 
of  the  limbs  due  to  retardation  of  growtli.  It  may  predispose 
to  deformity  by  the  general  weakness  that  it  causes,  or  the  trunk 
may  be  unbalanced  by  loss  of  function  in  one  of  tlie  upper 
extremities,  but  the  more  extreme  cases  of  deformity  are  caused 
by  unilateral  paralysis  of  the  muscles  of  tlie  trunk.  As  a  result 
the  expansion  of  one  side  of  the  thorax  is  interfered  with  and  thie 
unaffected,  or  less  affected,  side  taking  on  increased  activity, 
develops  at  the  expense  of  the  disabled  part.  Thus,  the  con- 
vexity of  the  curve  is  usually  toward  the  sound  part. 

4.  lyATEltAL      Cl'RVATURE     SECONDARY     TO      DlsEASE     A\ITJIIN 

THE  Thoracic  Walls. — The  most  conmion  cause  of  deformity 
of  this  class  is  persistent  empyema.  The  lung  is  primarily  com- 
pressed by  the  effused  fluid,  and  its  function  is  finally  impaired 
or  abolislied  by  the  adhesions  that  form  between  it  and  the  chest 


166 


ORTHOPEDIC  SURGERY 


wall,  as  well  as  by  the  extension  of  the  disease  to  its  structure. 
As  a  result,  the  side  of  the  chest  is  retracted  while  the  function  of 
the  unaffected  lung  is  increased  (Fig.  99).  Thus,  as  in  paralysis, 
the  spine  curves  witli  the  convexity  toward  the  active  side. 

Other  affections  of  the  lungs  that  interfere  with  the  function 
of  one  side  may  induce  lateral  curvature,  but  the  influence  is  less 
marked  and  direct  than  in  empyema. 


Fig.  99 


Fig.  100 


Scoliosis  following  empyema  at  the  age 
of  two  years. 


Present  age  nineteen  years.     Scoliosis  secondary  to 
lumbar  Pott's  disease  in  early  childhood. 


5.  Incidental  T.ateral  Curvature.  Lateral  curvature 
may  be  cau.sed  })y  direct  injury  or  by  disease  of  the  spine;  for 
example,  Ijy  fracture  or  by  Pott's  disease,  or  by  other  organic 
affections  of  tlic  spine  (Fig.  100).  Distortion  symptomatic  of 
sacroiliac  disease,  or  the  more  marked  deformity  caused  ))y 
.sciatic  or  himfnir  iiciiritis  (Fig.  85),  may  if  persistent  finally 
induce  slight  pcniiiuiciil.  dcforinity,  but  such  cases  hardly  deserve 
special  consideration. 


LATERAL   CURVATURE   OF  THE  SPINE 


167 


6.  Lateral  Curvature  due  to  Occupation. — Lateral  curva- 
ture of  a  mild  degree  is  incidental  to  certain  occupations  that 
require  habitual  inclination  of  the  body.  It  is  said  to  be  very 
common  among  stone-cutters,  for  example.  Such  deformity 
developing  after  the  growth  of  the  body  has  been  attained  is  of 
interest  as  throwing  light  upon  the  etiology  of  the  ordinary  form 
of  lateral  curvature.  For  if  habitual  attitudes  can  thus  change 
the    contour    of    the   developed  spine,  it  is  evident  that  similar 


Fig.  101 


Fig.  102 


Congenital  scoliosis. 


Uliachitic  scoliosis. 


postures,  though  far  less  constant,  may  influence  the  spine  of  a 
growing  child,  particularly  in  one  predisposed  to  such  distortion. 
7.  Congenital  Lateral  Curvature. — Congenital  scoliosis 
is  uncommon  in  infants  otherwise  normal  (Fig.  101),  but  several 
cases  have  come  under  my  observation  at  an  age  sufficiently 
early  to  make  diagnosis  absolutely  certain.  One  case,  in  an 
otherwise  well-formed  male  infant,  was  seen  at  the  age  of  tliree 


1(38  ORTHOPEDIC  SVBGERY 

months.  There  was  well-marked  lateral  deviation  with  rotation 
in  the  dorsal  region  that  had  attracted  attention  soon  after  birth. 
A  second  case,  in  a  female  child,  was  seen  at  about  the  same 
age.  The  deformity  was  extreme,  and  contracted  tissues  on 
the  concave  side  prevented  the  straightening  of  the  spine.  There 
was  also  an  accompanying  lumbar  hernia. 

The  first  patient  was  cured  by  manipulation  and  posture  before 
the  completion  of  the  first  year;  the  second  is  still  under  treat- 
ment. A  number  of  cases  have  been  collected  from  literature 
bv  A.  Perrone.^  Lateral  curvature  is  often  associated  with 
congenital  defects  or  malformations;  for  example,  with  congenital 
elevation  of  the  scapula,  with  congenital  torticollis  with  cervical 
ribs,  with  rhachischisis  and  the  like. 

8.  Rhachitic  Lateral  Curvature.  Rhachitis  predisposes 
to  deformity  of  all  parts  of  the  body  by  weakening  resistance 
of  all  the  tissues.  As  is  well  known,  the  common  deformities 
from  this  cause  are  the  so-called  rhachitic  kyphosis  that  develops 
in  the  sitting  child,  and  the  distortions  of  the  lower  extremities 
in  those  who  stand  and  walk.  Lateral  curvature  of  the  spine 
sometimes  accompanies  the  kyphosis  in  those  who  do  not  walk, 
or  it  may  exist  independently  of  it.  The  lateral  inchnation  is 
induced  doubtless  by  the  manner  of  sitting  or  by  the  manner  in 
which  the  child  is  supported  on  the  mother's  arm;  for  at  this 
period  of  rapid  growth  and  increased  susceptibility  to  deforming 
influences,  even  slight  and  temporary  causes  of  this  nature  may 
be  sufficient  to  induce  the  distortion  (Fig.  102).  Again,  when 
the  child  begins  to  walk,  the  tilting  of  the  pelvis  due  to  distortion 
of  the  limbs,  for  example,  to  unilateral  knock-knee,  may  also 
serve  to  disturb  the  equilibrium  of  the  body  and  thus  to  induce 
lateral  distortion. 

How  common  rhachitic  lateral  curvature  may  be  it  is  impossible 
to  say,  but  it  is  probable  that  if  all  rhachitic  infants  and  children 
were  carefully  examined  this  deformity  would  be  discovered  in 
many  instances  in  which    its   existence  had  not  been  suspected. 

Mayer^  examined  220  rhachitic  infants  with  reference  to  this 
point,  and  in  all  l)ut  3  found  scoliotic  deformity.  This  is  not  in 
accord  witli  my  own  experience,  but  I  am  convinced  that  rhachitis 
is  of  far  greater  importance  in  the  etiology  of  lateral  curvature 
of  the  spine  than  is  generally  l)elieved,  and  that  a  large  proportion 
of  th*e  severe  and  iiitrac<nl)h'  cases  may  be  traced  to  this  canse. 

lUelxT  KniiKcnil.iU^  Skoliosc,  /oils.    f.   Oitli.i.   Cliir.,    I!)0(;,    H.   \v.,  U.  2. 
2  Hull.  Mi'ilic-iU',  .luiic  \r,,  litOl. 


LATERAL  CURVATURE   OF  THE  SPINE  ]69 

In  about  15  per  cent,  of  the  cases  tabulated  \)y  Truslow  the 
influence  of  one  or  more  of  the  causes  that  have  been  enumerated 
seemed  to  be  apparent,  viz. : 

Congenital  (leff>rmity        .      : 2 

Torticollis 2 

Empyema 4 

Anterior  poliomyelitis 3 

Inequality  of  the  leK.s  of  mfiie  than  half  an  inch 6 

Rhanhitis 1.3 

Total 30 


Fic.   103 


Posture  induced  by  improper  desk  and  chair.      (Scudder.) 


In  the  remaining  85  per  cent,  of  the  cases  the  direct  cause 
of  the  deformity  was  uncertain. 

Hereditary  Influence. — By  many  writers  the  influence  of  herecHty 
is  considered  an  important  factor  in  the  etioU)gy.  That  th.ere  is 
such  an  influence,  predisposing  to  (Hsease  as  well  as  to  deformity, 
is  undoubted,  but  it  is  very  difficult  to  establish  its  connection 
with  ordinary  cases.  In  eleven  of  201  cases,  lateral  curvature 
was  present  in  either  th.e  father  or  mother  of  the  patient;  and  in 
seventeen  others  a  brother  or  sister  of  the  patient  was  dct'oriiicd 
in  a  similar  manner. 


170 


ORTHOPEDIC  SURGERY 


OccuPATiox. — It  is  well  known  that  occupation  may  induce 
deformity  in  the  adult,  and  one  looks  naturally  to  occupation  as 
a  factor  in  the  causation  of  lateral  curvature  in  childhood.  Occu- 
pation in  this  class  implies  school,  and  it  is  well  known  that  fatigue 
during  school  hours  may  induce  improper  postures,  especially 
if  the  chair  is  unsuitable  or  uncomfortable.  The  influence 
of  habitual  posture  is  indicated  in  the  statistics  of  lateral  curvature 
among  school-children  recorded  by  Scholder,  Werth,  and  Combe,^ 
the  proportion  of  deformity  steadily  rising  from  the  lower  to 


Fig.  104 


Posture  induced  by  improper  chair.      (Scudder.) 

the  higher  classes  (Figs.  103  and  104).  Under  the  influence  of  con- 
stantly recurring  fatigue  an  improper  attitude  is  likely  to  become 
habitual,  its  character  being  influenced  by  the  arrangement  of  the 
light  or  by  the  shape  of  the  desk.  When  a  habit  of  posture  has 
been  acquired  it  is  likely  to  persist  when  the  sitting  posture  is 
assumed  elsewhere  than  at  school,  and  the  greater  liabihty  of 
girls  to  the  deformity  may  be  explained  in  part  by  the  fact  that 
they  sew,  or  read,  or  play  on  the  piano  at  times  when  boys  are 
usually  engaged  in  active  exercise. 

In  400  cases  of  lateral  curvature  under  treatment  at  the  Hos- 
pital for  Ruptured  and  Crippled,  the  occupation  and  habits  that 
may  have  influenced  the  deformity  were  recorded: 

'  Loc.  cit. 


LATERAL    CURVATURE   OF   THE  SPINE  171 

Occupation: 

School 285 

Factory 19 

Clerk 13 

Domestic 8 

MiUiuery,  dressmaking,  etc 8 

Messenger 3 

Housewife 3 

Teacher 2 

No  occupation 59 


Total 400 


Posture: 


Weight  on    right  foot 48 

"     left  " 48 

—  96 
Carries  books  or  bab.v  on  right  arm 38 

"  "  left  arm 36 

—  74 

Sits  at  desk  or  work  in  faulty  attitude 57 

Carries  heavy  load  on  one  shoulder 2 

Excessive  use  of  right  arm  in  occui)ation .      .  3 

Total 232 


The  sitting  posture  is  not  the  only  one  in  which  improper 
attitudes  may  be  persistently  assumed,  for  even  posture  chiring 
sleep  may  influence  the  inclination  of  the  body  during  the  hours 
of  activity.  But  the  sitting  position  is  the  one  in  which  the 
muscular  support  is  most  likely  to  be  relaxed,  and  in  which 
a  tendency  toward  lateral  inclination  is  most  likely  to  be 
acquired,  since  children  do  not  often  retain  a  fixed  attitude  in 
the  erect  position  for  any  length  of  time.  Bradford  and  Lovett 
record  an  observation  of  the  attitudes  of  sixty-seven  healthy 
adults  undergoing  a  written  examination.  At  the  end  of  the 
second  hour  a  lateral  inclination  of  the  body  was  evident  in  all, 
and  in  three-fourths  of  the  number  the  general  inclination 
of  the  body  was  to  the  right.  In  about  this  proportion  of  the 
cases  of  lateral  curvature  the  type  of  fixed  deformity  is  to  the  left 
in  the  lumbar  and  to  the  right  in  the  dorsal  region  Assuming  that 
the  distortion  is  caused  or  influenced  by  the  habitual  attitude 
during  school  hours  it  would  appear  that  the  primary  deformity 
should  be  more  often  of  the  lumbar  region,  for  in  the  sitting 
posture  the  lumbar  lordosis  is  lessened  or  lost;  thus  the  bodies  of 
the  vertebme  in  the  lumbar  region  are  subjected  to  greater  pressure 
than  in  the  dorsal  region — a  pressure  which  might  induce  tlie 
accommodative  changes  in  the  bones  that  accompany  persistent 
deformity. 

The  possibility  of  distinguishing  the  varieties  of  lateral  curva- 
ture in  which  tlie  primary  distortion  is  lunil)ar  from  those  in 
wliicli  it  is  dorsal,  by  the  flattening  of  the  (h)rsal  kypliosis  in  the 


172  ORTHOPEDIC  SURGERY 

former,  and  its  exaggeration  in  the  latter  instance,  has  been 
mentioned. 

Varieties  of  Deformity.  According  to  statistics  from  various 
sources,  about  tl  ree-fourths  of  the  well-developed  double  curves 
of  the  spine  are  convex  to  the  right  in  the  dorsal  and  to  the  left 
in  the  lumljar  region,  and,  as  the  distortion  of  the  thorax  is  more 
noticeable  of  the  two,  it  usually  classifies  the  deformity  as  right 
or  left.  The  dorsal  curvature  may  be  either  primary  or  secondary, 
and  the  relative  frequency  of  the  original  deformity,  whether  lumbar 
or  dorsal,  is  in  doubt,  with  the  probability  in  favor  of  the  former. 

Summary  of  varieties  of  deformity  of  the  spine  under  treatment, 
1899-1900,  at  the  Hospital  for  Ruptured  and  Crippled,  tabulated 
by  Dr.  Truslow: 

1.  Simple  anteroposterior  deformities: 

(a)  Kyphosis 10 

Kypholordosis 1 

Lordosis 1 

—  12 
Round  .shoulders: 

(b)  Abducted  scapulae 7 

Elevated  scapulse 2 

—  9 

2.  Anteroposterior    abnormalities    most    m.arked,  but  accompanied  by 

lateral  deviation: 

(a)   With  single  lateral  curve 14 

(6)   With  double  lateral  curves 16 

(c)  With  triple  lateral  curves 7 

—  37 

3.  Rotation  more  marked  than  lateral  deviation: 

(a)  With  <loublc  lateral  curves 22 

(6)   With  triple  lateral  curves 8 

—  30 

4.  Lateral    deviation    more    marked    than    rotation;    direction    of    the 

curves: 
Right  dor.sal,  left  lumbar  type: 

(a)  Single  lateral  curve 22 

(b)  Double  lateral  curve.s 17 

(c)  Triple  lateral  curves f> 

—  99 
Left  dorsal,  right  lumbar  tyi)c: 

(a)  Single  lateral  curve 3 

(h)   Double  lateral  curves 8 

(c)    Triple  lateral  curve.s 3 

—  14 

Total 201 

It  will  be  noted  that  in  twenty-one  cases,  anteroposterior 
deformity  was  present  without  lateral  deviation,  and  that  in 
thirty'-ieven  instances  it  was  accompam'ed  by  lateral  deviation. 
In  the  remaining  144  cases,  rotation  was  more  marked  than 
lateral  deviation  in  80  cases,  and  lateral  deviation  jnore  marked 
than  rotation  in  llo.  In  the  entire  number  of  cjises  in  which 
lateral  deviation  was  present  it  was  singht  in  89  cases,  double 
in  117  ca-ses,  triple  in  24  cases. 


LATERAL    CURVATURE   OF   THE  SPINE  173 

111  S90  cases  of  lateral  curvature  tabulated  by  Schultliess  the 
deformity  was  as  follows:^ 

Left.  Rioht.      Total. 

Total  scoliosis  (single  curve  affecting  the  entire  si^ine)       .      173  23  196 

Lumbar  scoliosis  (single  curve  limited  to  the  lumbar 

region) 63  34  97 

Lumbodor.sal  scoliosis  (single  curve  limited  to  lumhu- 

dorsal  region) 184  104  348 

Complicated  scoliosis: 

(a)   Right,  dorsal,  left  lumbar      .      .      .  191 

(6)   Left  dorsal,  right  lumbar .58  ...  249 

478  412  890 

It  will  ])e  noted  that  a  very  large  proportion  of  these  ca.ses 
were  in  the  early  stage  of  deformity,  as  indicated  by  the  absence 
of  compensatory  curves;  that  in  SO  per  cent,  of  the  293  cases  in 
which  the  curve  was  general  or  most  marked  in  the  luinl)ar 
region,  the  inclination  was  to  the  left,  and  of  the  complicated  or 
more  fully  developed  cases  in  which  the  curve  was  double,  73  per 
cent,  were  of  the  right  dorsal,  left  lumbar  type. 

Symptoms. — In  the  large  proportion  of  cases  the  first  symp- 
tom is  the  deformity.  This  is  often  discovered  by  the  dress- 
maker at  the  age  when  the  clothing  is  made  to  fit  the  figure  more 
closely.  In  certain  instances  the  deformity  may  be  preceded  or 
accompanied  by  pain.  This  was  present  to  a  greater  or  less 
degree  in  about  one-quarter  of  the  cases  examined  by  Truslow. 
Pain  may  be  simply  the  discomfort  or  the  "dragging"  sensation 
of  fatigue,  usually  referred  to  the  lumbar  region,  or  it  may  be 
severe  and  neuralgic  in  type.  The  latter  variety  is  more  common 
in  the  cases  in  which  the  deformity  is  extreme.  It  is  said  to  be 
the  result  of  pressure  on  nerves,  but  this  cause  is  exceptional  in 
ordinary  cases,  as  it  Ls  as  often  referred  to  the  convex  as  to  the 
concave  side.  When  the  deformity  ls  extreme — for  example, 
when  the  ribs  and  the  iliac  crest  are  in  contact — direct  pressure 
may  explain  the  local  discomfort  referred  to  this  region. 
There  are  also  more  general  symptoms  of  a  neurasthenic  or 
hysterical  nature  that  may  be  due  in  part  to  the  deformity  and 
in  part  to  the  debility  of  which  it  may  be  a  result  or  accompani- 
ment. For  it  must  l)e  borne  in  mind  that  lateral  curvature  is 
one  of  the  postural  deformities  whose  development  Ls  favored 
by  general  weakness,  as  illustrated  by  the  fact  that  it  is  often 
accompanied  by  other  deformities  of  similar  nature,  particularly 
by  the  weak  font.  Deformities  of  this  class  which  are  induced 
by  weakness,  in  their  turn  tend  to  prolong  and  to  aggravate  it 
by  hampering  normal  development  and  normal  function. 

•  Zeits.  f.  Orth.  Chir.,  1902,  Bd.  x. 


174  ORTHOPEDIC  SURGERY 

In  many  instances  symptoms  of  weakness  and  awkwardness 
precede  the  deformity.  Truslow  states  that  in  a  large  proportion 
of  the  cas?s  investigated,  the  patients  had  been  distinctly  less 
active  than  their  companions,  that  they  did  not  enjoy  exercise, 
and  were  inclined  to  lead  sedentary  lives.  Teschner^  has  called 
attention  to  the  same  peculiarity.  He  states  that  the  patients 
are  often  indifferent,  apathetic,  and  lazy.  He  has  noted  also  a 
peculiar  lack  of  co-ordination  and  muscular  control  as  a  com- 
mon accompaniment  of  the  deformity.  These  symptoms  apply 
particularly  to  adolescence,  the  period  of  rapid  growth  and 
instability,  when  any  latent  deformity  or  weakness  is  likely  to 
be  exaggerated.  In  younger  subjects  such  symptoms  are  far 
less  marked  or  are  absent.  In  the  cases  in  which  the  deformity 
is  extreme,  symptoms  due  to  interference  with  the  respiratory  and 
circulatory  apparatus,  or  to  displacement  of  the  abdominal 
organs,  may  be  present.  Such  symptoms  are,  however,  rather 
unusual  in  cases  of  the  ordinary  type. 

Diagnosis.  Posture. — Lateral  curvature  of  the  spine  is  a  simple 
deformity  unaccompanied  by  the  symptoms  of  disease.  Wlien 
the  patient  stands  with  the  back  and  hips  bare,  the  inclination 
of  the  body  to  one  or  the  other  side  and  the  general  want  of  sym- 
metry are  usually  apparent,  even  in  the  earliest  stage  of  the  affec- 
tion. For,  as  has  been  stated,  the  habitual  assumption  of  a  certain 
posture  precedes  fixed  changes  in  and  about  the  spine,  and  this 
posture  will  appear  when  the  patient  is  asked  to  stand  in  the 
usual  manner.  If  the  inclination  of  the  body  is  toward  the  left 
(Fig.  88),  the  left  arm  will  hang  in  close  apposition  to  its  lateral 
border,  while  on  the  right  side  an  interval  will  appear  between 
the  arm  and  the  trunk.  If  there  is  a  slight  lumbar  curve  to  the 
left  (Fig.  90),  the  right  iliac  crest  will  be  accentuated.  The 
curvature  in  the  dorsal  region  raises  one  shoulder  (Fig.  99),  the 
scapula  on  the  affected  side  projects,  and  the  distance  between 
its  posterior  border  and  the  median  line  is  increased.  Rotation 
of  the  spine  is  shown  by  the  fulness  or  projection  of  one  side  ac- 
companied by  a  corresponding  flatness  on  the  other.  This  is 
more  nfjticeable  when  the  patient  bends  the  body  forward  so  that 
the  horizontal  plane  of  the  back  is  brought  into  view  (Fig.  89), 
Corresponding  changes,  though  of  a  less  marked  degree,  appear 
on  the  anterior  surface  of  the  body;  for  example,  the  apparent 
diminution  in  the  size;  of  the  mamma  on  the  side  opposite  the 

'  Medical  Record,  IJcccinber  10,  1893. 


LATERAL   CURVATURE   OF  THE  SPINE  175 

convexity  of  the  posterior  curve  and  its  relative  depression  or 
elevation   may   attract   attention. 

It  seems  probable  that  a  change  in  the  anteroposterior  contour 
of  the  spine  precedes,  in  many  instances,  the  lateral  deviation. 
Thus,  a  general  droop  of  the  body  associated  with  round  shoulders 
and  a  flattening  of  the  chest  may  be  regarded  as  a  predisposing 
cause  or  an  early  symptom  of  more  serious  deformity. 

Mobility. — As  has  been  mentioned,  it  may  be  assumed  that 
habitual  posture  precedes  actual  deformity.  Habitual  posture 
implies  disuse  of  certain  attitudes  and  motions,  thus  limitation 
of  the  normal  flexibility  of  the  spine  is  one  of  the  earliest  signs 
of  progressive  deformity.  The  test  of  the  motion  of  the  different 
regions  of  the  spine  Ls,  therefore,  a  necessary  part  of  the  examina- 
tion. To  test  the  motion  in  the  lumbar  region,  one  fixes  the 
pelvis  with  the  hands  while  the  patient  sways  the  body  in  the 
four  directions  and  rotates  it  from  side  to  side.  It  is  suggested 
by  Bradford  and  Lovett  that  direct  lateral  flexibility  may  be 
tested  by  placing  blocks  of  wood  under  one  foot  until  the  limit 
of  lateral  flexion  is  reached,  as  shown  by  the  inability  of  the 
patient  to  hold  the  elevated  limb  in  the  extended  position.  The 
experiment  is  then  repeated  on  the  opposite  side.  The  flexi- 
bility of  the  upper  part  of  the  trunk  may  be  tested  by  fixing  the 
part  below  with  the  hands  while  the  patient  flexes,  extends,  and 
rotates  the  body.  It  is  important,  also,  to  test  the  range  of  motion 
at  the  shoulder-joints.  The  normal  individual  should  be  able 
to  hold  the  arms  extended  directly  above  the  head  without  in- 
creasing the  lumbar  lordosis.  In  many  instances,  however,  it 
will  be  found  that  there  is  a  marked  restriction  of  this  motion; 
in  fact,  such  restriction  is  almost  always  an  accompaniment  of 
so-called  round  shoulders. 

The  height  and  weight,  the  circumference  and  the  expansion 
of  the  chest  should  be  investigated,  and  a  test  of  the  muscular 
strength,  not  only  of  the  muscles  of  the  trunk,  but  of  the  mem- 
bers as  well,  is  of  advantage  as  throwing  light  on  the  etiology 
and   indicating  the  general   line  of  treatment. 

Record. — The  most  reliable  of  the  graphic  records  to  be  used 
in  connection  with  the  history  are  photographs.  The  patient 
may  stand  behind  a  thread  screen  (Fig.  105)  in  the  habitual  atti- 
tude. The  spinous  processes,  the  iliac  crests,  and  the  angles  of 
the  scapulie  having  been  marked,  the  exact  amount  of  lateral 
deviation  of  the  trunk  will  be  shown.  The  rotation  may  be  indi- 
cated also  by  photographing  the  patient  in  the  recumbent  posture. 


176 


ORTHOPEDIC  SURGERY 


Fin.    lOo 


The  rotation  of  the  spine  is  the  most  important  indication  of 
deformity.  This  may  be  recorded  with  sufficient  accuracy  by 
taking  direct  tracings  of  the  trunk  at  fixed  points  by  means 
of  a  lead  or  zinc  tape  while  the  patient  lies  in  the  recumbent 
posture. 

At  the  Hospital  for  Ruptured  and  Crippled  the  shadow  of  the 
trunk  cast  by  an  electric  light  at  a  fixed  distance  is  traced  upon 
a  large  sheet  of  paper.     Upon  this  outline  the  position  of  the 

more  important  landmarks  is 
indicated.  The  degree  of  ro- 
tation is  shown  by  transverse 
tracings  and  the  line  of  the 
spinous  processes  is  ascer- 
tained by  applying  a  broad 
strip  of  adhesive  plaster  to 
the  back  upon  which  the  tip 
of  each  spinous  process  is 
marked.  The  anteroposterior 
outline  of  the  spine  should 
be  recorded,  also  the  general 
attitude  and  the  presence  or 
absence  of  other  evidences 
of  weakness  such  as  knock- 
knees  and  weak  feet. 

Prognosis. — In  the  devel- 
opment of  lateral  curvature 
there  is  doubtless  a  prelimi- 
nary or  predisposing  stage — 
a  stage  of  progression  and  a 
stage  of  arrest.  All  deformi- 
ties of  this  class  are  more 
likely  to  progress  during  the 
growing  period.  They  are 
likely  to  become  stationary 
when  the  period  of  growth  is 
comj)leted.  Tims,  the  prognosis  is  worse  when  the  deformity 
begins  at  an  early  age  than  when  it  first  appears  in  adolescence. 
The  most  extreme  and  intractable  of  the  simple  cases  are  the 
result  of  rl.achitis,  in  whicli  the  deformity  appearing  in  infancy 
or  early  childhood  has  increased  with  the  growth  of  the  child. 

If  the  causes  of  (l(;formity  are  such  that  they  operate  to  check 
the  e(|ual  development  of  the  afi'ected  part,  the  prognosis  is  even 


-A 

\^v\  ]  !       ^flHHU         ''v 

H^'<B=:^i 

^^^Iv^         'H 

.-,  .jTi^^i     .      '  m 

i       i                                        ^^ 

L,    1      ,              \               VH 

H                      '  '  'Vra        ^1 

^HB          ^^^^Bi^                   ^^^gg  J        ^B 

^■K       ^HHP .                      ^^H        ^H 

^^K  l^f                                    V^fl 

^Hp  V                          U|H 

m    :;fE-;2| 

The  thread  ncreen.     From  the  Boston  Children's 
Hosijital  Report. 


LATERAL   CURVATURE  OF  THE  SPINE  177 

more  directly  influenced  by  the  age  of  the  patient.  For  example, 
empyema,  even  if  the  lung  is  irreparably  damaged,  does  not  cause 
appreciable  deformity  in  the  adult,  but  in  childhood  the  functional 
activity  and  the  growth  of  the  side  of  the  thorax  are  checked,  in 
addition  to  the  direct  effect  of  the  adhesions  and  contractions  due 
to  the  disease;  thus,  the  deformity  is  likely  to  be  progressive  in 
spite  of  the  treatment.  The  same  is  true  of  paralytic  deformity. 
In  the  ordinary  type  of  lateral  curvature  in  the  adolescent  girl 
the  prognosis  is  influenced,  of  course,  by  the  general  condition 
of  the  patient  and  by  the  character  of  the  occupation.  As  far 
as  the  local  deformity  is  concerned,  the  prognosis  as  regards  im- 
provement or  cure  depends  in  great  measure  upon  the  fixed  changes 
that  have  taken  place,  and  upon  the  degree  of  voluntary  and 
involuntary  rectification  that  is  possible.  In  some  instances  the 
postural  distortion  may  be  considerable,  yet  the  fixed  deformity 
may  be  very  slight,  while  in  other  instances  the  fixed  rotation  of 
the  spine  may  be  marked,  although  the  lateral  distortion  is  less 
noticeable. 

A  single  curve  is  more  amenable  to  treatment  than  is  a  double 
or  triple  distortion,  because  it  indicates  an  earlier  stage  of  de- 
formity and  because  the  treatment  may  be  more  effective  when 
applied  to  one  deformity  than  to  several.  If,  however,  the  single 
curve  is  fixed,  the  appearance  of  a  secondary  or  compensatory 
curve  at  another  part  of  the  spine  is  probable,  in  spite  of  pre- 
ventive  treatment. 

In  the  majority  of  cases,  fixed  deformity  of  the  spine  as  indi- 
cated by  rotation  is  already  present  when  the  patient  is  brought 
for  treatment.  This  fixed  deformity  might  be. overcome  doubt- 
less in  certain  cases,  and  complete  cure  might  be  obtained  were 
all  conditions  favorable.  But  in  the  ordinary  sense  a  cure  means 
the  relief  of  symptoms,  the  checking  of  the  progress  of  deformity, 
and  the  restoration  of  the  general  symmetry  of  the  trunk.  Such 
a  cure  may  be  obtained  in  most  instances.  The  deformity  of 
the  spine  becomes  symmetrically  divided  on  either  side  of  the 
median  line,  the  changes  incident  to  maturity,  particularly  the 
increased  amount  of  adipose  tissue,  serve  to  conceal  the  irregu- 
larities of  the  outline,  and  the  history  of  the  distortion  is  completed. 

In  certain  instances,  particularly  in  well-marked  cases,  the 
deformity  may  increase  in  adult  life  and  even  in  old  age.  In 
such  cases,  the  symptoms  of  discomfort  and  actual  pain  may  be 
troublesome  throughout  life,  especially  in  the  overworked  and 
debilitated  class.     The  symptoms  directly  incident  to  the  om- 

12 


178  ORTHOPEDIC  SURGERY 

pression  and  distortion  of  the  internal  organs  have  been  men- 
tioned. 

The  great  majority  of  cases  that  develop  or  that  are  discovered 
in  adolescence  progress  for  a  time  and  come  to  an  end  on  the 
cessation  of  growth,  causing  finally  no  symptoms  other  than  the 
loss  of  symmetry  that  may  be  more  or  less  satisfactorily  concealed 
by  the  art  of  the  dressmaker  and  by  the  corset. 

It  would  appear,  then,  that  lateral  curvature  of  the  spine  is 
always  of  sufficient  gravity  to  merit  treatment  and  supervision 
until  its  cure  or  arrest  is  assured.  If  its  discovery  leads  to  active 
efforts  to  improve  the  general  condition  and  to  avoid  unhealthful 
influences  it  may  be  even  of  benefit  to  the  patient. 

Lateral  curvature  in  a  young  child  is  of  far  greater  importance 
than  in  an  older  subject  because  of  the  probability  of  an  increase 
of  deformity.  Extreme  deformity  is  always  a  source  of  weakness 
and  usually  of  discomfort  to  the  patient.  Incipient  deformity 
may  be  cured  and  cure  is  not  impossible  even  when  deformity 
is  more  advanced,  but  in  this  more  than  in  any  other  postural 
deformity,  absolute  cure  implies  early  diagnosis  and  prevention, 
rather  than  the  correction  of  fixed  distortion. 

Recapitulation. — It  seems  probable  that  in  the  ordinary  type 
of  lateral  curvature  of  the  spine,  the  first  step  is  a  change  in  the 
relation  of  the  bodies  of  the  vertebrae  to  one  another;  that  a 
persistent  lateral  inclination  and  rotation  of  the  anterior  part  of 
the  column  precedes  the  lateral  inclination  of  the  trunk  which 
first  calls  attention  to  the  deformity.  This  postural  distortion 
becomes  fixed  by  accommodative  changes  in  the  muscles  and  other 
tissues  about  the  spine,  and,  finally,  it  is  confirmed  by  changes 
in  the  shape  of  the  vertebral  bodies  and  by  the  general  changes 
in  the  trunk  as  a  whole.  Thus,  if  one  might  observe  the  incep- 
tion and  development  of  lateral  curvature  of  the  common  type 
he  would  note,  first,  that  the  trunk  was  more  often  flexed  to  one 
side  than  to  the  other,  and  that  this  attitude  gradually  became 
habitual.  Lateral  inclination  of  the  trunk  necessitates,  of  course, 
lateral  deviaticjn  and  rotation  of  the  bodies  of  tlie  vertebrae,  and 
the  habitual  assumption  of  such  a  posture  implies  disuse  of  other 
postures  and  thus  disuse  of  normal  motion. 

Disuse  of  motion  in  any  direction  is  followed  by  diminished 
power  in  the  inactive  muscles,  and,  as  has  been  stated,  habitual 
deformity  is  followed  by  accommodative  changes  to  a  greater  or 
less  degree  in  the  various  tissues  whose  functions  have  been 
changed  or  modified. 


LATERAL   CUEVATUEE   OF  THE  SFI^'E  179 

Thus  the  progress  of  the  deformity  would  be  shown: 

1.  By    the    habitual    assumption    of    an    attitude    simulating 
deformity. 

2.  By  limitation  of  motion  in  the   directions  opposed  to  the 
habitual  attitudes. 

3.  By  fixed  lateral  deviation  of  the  spine  accompanied  by 
rotation  or  twisting  of  the  column. 

One  rarely  has  the  opportunity  to  note  the  development  of 
lateral  curvature,  and  when  patients  are  brought  for  treatment 
fixed  deformity  is  usually  present.  It  is  extremely  difficult  to 
entirely  overcome  fixed  distortion,  while  it  ls  comparatively  easy 
to  correct  simple  postural  deformity  in  which  the  secondary 
changes  are  absent  or  but  slightly  advanced.  On  this  account  it 
is  customary  to  divide  lateral  curvature  into  two  classes — the 
true  and  the  false — or  to  speak  of  rotary  lateral  curvature  as 
distinct  from  lateral  curvature.  Thus,  the  term  true  or  rotary 
curvature  would  be  limited  to  those  cases  in  which  the  changes 
are  fixed  and  in  which  cure  is  practically  impossible,  while  false 
or  simple  or  postural  lateral  curvature  would  include  the  early  or 
curable  class.  But  as  the  two  forms  are  simply  stages  in  the 
same  process  it  would  seem  preferable  to  speak  of  the  incipient 
and  the  later  stages  of  lateral  curvature,  or  of  reducible  or  irre- 
ducible deformity,  the  distinctions  that  are  made  in  classifjdng 
distortions  of  similar  origin  elsewhere. 

This  point  of  view  is  of  advantage  because  it  relieves  the  sub- 
ject of  much  of  the  obscurity  that  has  resulted  from  this  arbitrary 
division.  It  emphasizes  the  fact,  also,  that  the  habitual  assump- 
tion of  an  improper  attitude  that  simulates  deformity  is  the  first 
step  toward  permanent  distortion,  particularly  in  individuals  who 
by  inheritance  or  by  constitutional  tendency  or  by  occupation  are 
predisposed  to  it. 

The  Prevention  of  Deformity. — Prevention  includes  the  avoid- 
ance of  all  the  predisposing  or  exciting  causes  of  weakness  as 
well  as  of  deformity.  These  it  is  hardly  necessary  to  enumerate. 
The  first  and  most  important  preventive  measure  Ls  the  dis- 
covery of  deformity  or  the  tendency  to  deformity  at  a  time  when  it 
may  be  checked  or  cured.  To  discover  deformity  at  this  period 
of  its  development  one  must  look  for  it,  and  it  would  seem  that 
regular  inspection  of  the  naked  bodies  of  all  children  should 
become  a  routine  practice  of  the  family  physician.  Deformity 
in  this  sense  includes  not  only  fixed  distortions,  but  improper 
attitudes  and  postures  of  every  variety  as  well. 


180 


ORTHOPEDIC  SURGERY 


The  importance  of  the  attitude  which  is  habitually  assumed 
during  occupation  has  been  mentioned.  Therefore,  the  provision 
of  proper  desks  and  seats  for  school-children  is  a  very  essential 
part  of  preventive  treatment. 

The  seat  of  the  chair  should  be  deep  enough  to  support  the 
thighs,  vet  it  should  not  interfere  with  flexion  at  the  knees.  It 
should  be  of  such  height  as  to  allow  the  feet  to  rest  firmly  on  the 
floor,  and  it  should  be  inclined  slightly  backward.  The  back  of 
the  chair  should  extend  to  about  the  level  of  the  shoulders;  it 
should  be  inclined  slightly  backward,  but  arched  somewhat  for- 
ward in  the  lumbar  region  in  order  to  conform  to  the  normal 
lordosis  when  the  child  sits  in  the  erect  posture.  The  desk  should 
be  as  close  to  the  body  as  is  possible,  so  that  the  child  need  not 

Fig.  106 


Adjustable  school  desks  and  seats.     Scheiber  and  Klein.     (Redard.) 

lean  for  forward  when  reading  or  writing.  The  height  of  the 
desk  should  be  slightly  less  than  the  level  of  the  elbows  when 
the  chikl  sits  erect,  and  the  inclination  should  be  sufficient  to 
hold  the  book  at  the  proper  distance  from  the  eyes  (Figs.  106 
and  107).  The  vertical  handwriting  is  of  advantage  in  that  the 
children  are  taught  to  face  the  desk  squarely,  as  contrasted  with 
the  lateral  twist  of  the  body,  the  usual  attitude  for  writing. 

Treatment. — The  treatment  of  rotary  lateral  curvature  of  the 
spine  does  not  dift'er  in  principle  from  the  treatment  of  any  other 
weakness  or  dcfornn'ty,  but  the  application  of  this  ))rinciplc  is 
difficult  and  the  results  are  for  from  definite  and  satisfactory. 
This  explains,  doubtless,  the  apparently  opposing  theories  and 
methods  of  treatment  that  are  still  advocated. 


LATERAL  CURVATURE  OF  THE   SPINE 


181 


The  principles  of  the  treatment  of  any  form  of  weakness  not 
directly  induced  by  disease  are,  then : 

1.  To  overcome  all  restriction  to  passive  motion. 

2.  To  strengthen  the  weakened  muscles,  especially  those  whose 
action   is   opposed   to   habitual   deformity. 

3.  To   insist  on   the   avoidance  of  overfatigue   and   improper 
postures, 

4.  To  support  the  weak  part  by  a  brace  if  deformity  cannot 
be  prevented  otherwise. 

In  applying  these  principles  to  the  treatment  of  the  distorted 
spine  the  first  step,  the  removal  of  restriction  to  passive  motion 


Fig.  107 


Adjustable  school  seat.     (Miller  and  Stone.) 

in  all  directions,  is  difficult  because  of  the  variety  of  muscles  and 
other  tissues  that  may  have  become  involved,  and  because  the 
bodies  of  the  vertebr.e  lying  within  the  trunk,  of  which  the  dis- 
tortion ii  always  greater  than  of  the  spinous  processes,  can  be 
only  indirectly  affected  by  voluntary  or  by  passive  movements. 
The  cultivation  of  the  nuiscular  system,  and  ])arti('u]avly  of 
those  muscles  whose  action  is  opposed  to  the  habitual  deformity, 
is  the  second  indication  in  treatment.  As  applied  to  the  treat- 
ment of  the  weak  foot,  for  example,  in  which  the  adductor  and 


182  ORTHOPEDIC  SURGERY 

extensor  muscles  are  at  fault,  this  treatment  is  simple,  but  as 
applied  to  the  trunk  it  is  difficult,  because  there  are  in  nearly  all 
developed  cases  two  curves,  the  one  primary  and  the  other  second- 
ary, in  direction  directly  opposed  to  one  another.  These  op- 
posing curves  are  supplied  in  great  part  by  the  same  muscles, 
and  it  is  difficult  by  voluntary  effort  to  straighten  the  convexity 
of  one  without  at  the  same  time  increasing   that  of  the  other. 

The  third  principle  in  treatment  is  the  avoidance  of  predispos- 
ing attitudes  and  of  overwork.  This  again  may  be  more  easily 
applied  to  the  treatment  of  the  weak  foot;  first,  because  it  is 
relieved  from  strain  when  the  sitting  posture  is  assumed,  and  be- 
cause active  use,  as  in  walking,  may  be  utilized  as  an  exercise 
for  strengthening  the  muscles.  But  the  muscles  of  the  trunk  are 
not  exercised  to  any  extent  in  ordinary  walking,  which  is  for 
many  individuals  the  only  form  of  activity,  nor  is  the  spine  re- 
lieved from  weight  when  the  patient  is  seated.  On  the  con- 
trary, it  is  in  this  restful  attitude  that  the  deformities  of  the  spine 
are  usually  most  marked.  Thus,  only  in  the  recumbent  attitude  is 
the  spine  entirely  relieved  from  strain,  and  even  at  such  times  the 
deformity  may  be  favored  by  the  habitual  attitude  of  the  patient. 
The  weak  foot  may  be  supported  by  a  brace,  which  does  not  in- 
terfere with  its  activity,  but  which,  on  the  contrary,  aids  normal 
motion  by  holding  the  bones  in  proper  relation  to  one  another. 
But  in  the  treatment  of  the  spine  the  conditions  are  quite  differ- 
ent, since  it  cannot  be  supported  without  at  the  same  time 
restraining  its  normal  motion.  Finally,  no  brace  applied  to  the 
trunk  is  efficient,  for  while  it  may  prevent  the  lateral  deviation 
it  can  exercise  little  direct  action  on  the  rotation  of  the  spinal 
column. 

This  comparative  method  of  exposition  has  been  adopted  in 
order  to  illustrate  the  fact  that  it  is  not  the  difficulty  of  formu- 
lating principles,  but  the  difficulty  of  applying  them  that  makes 
the  therapeutics  of  rotary  lateral  curvature  of  the  spine  perplex- 
ing. In  practice  one  must  recognize  the  limitations  of  all  systems 
of  treatment  as  applied  to  this  particular  deformity,  and  select 
and  combine  methods  that  may  be  most  applicable  to  the  par- 
ticular case  under  treatment. 

For  example,  in  the  treatment  of  rhachitic  scoliosis  in  a  young 
child  one  cannot  count  upon  the  voluntary  assistance  of  the 
patient;  therefore,  treatment  l)y  simple  gymnastic  exercises  is 
impracticable.  In  this  class  of  cases  forcible  correction  of  the 
deformity  and    retention    by  a   plaster  support,   combined   with 


LATERAL    CURVATURE   OF   THE  SPINE  183 

massage,  and  even  the  removal  of  superincumbent  weight  by 
recumbency  on  the  stretcher  frame  would  be  treatment  of  selec- 
tion. At  this  age  the  trunk  is  flexible  and  the  deformity  may 
be  progressively  reduced  by  forcible  manipulation,  followed  by 
fixation  of  the  trunk  in  the  improved  position.  By  such  means 
one  may  expect  at  this  period  of  rapid  growth  to  induce  a  trans- 
formation of  the  deformed  vertebral  bodies  to  an  approximation 
at  least  of  the  normal.  The  correction  of  this  deformity  which 
must  almost  inevitably  increase  with  the  growth  of  the  patient 
would  quite  outweigh  the  disadvantage  of  depri^^ng  the  muscles 
of  their  normal  stimulus  during  the  corrective  period  of  treatment. 

In  the  ordinary  type  of  scoliosis  in  older  subjects,  particularly 
if  the  distortion  is  moderate  in  degree  and  the  changes  in  the 
bones  but  slight,  one  would  expect  to  attain  the  best  result  by 
gymnastic  training  and  by  regulation  of  the  postures.  Although 
even  in  this  class  supports  may  be  of  service,  if  by  such  means 
the  trunk  may  be  held  in  an  overcorrected  attitude  until  the 
deformity  habit  is  overcome. 

The  advisability  of  a  change  of  occupation  has  been  mentioned. 
It  is  probable  that  if  the  patient  with  incipient  or  even  more 
pronounced  curvature  of  the  spine  were  removed  from  school, 
were  transferred  to  the  country  where  during  the  succeeding  years 
of  childhood  and  adolescence  much  of  the  time  might  be  passed 
in  active  exercise  in  the  open  air,  the  final  result  would  compare 
very  favorably  with  that  attained  by  active  treatment  under  less 
favorable  circumstances.  Such  complete  change  of  occupation 
and  surroundings  is,  of  course,  impracticable  in  most  instances. 
Lateral  curvature  of  the  spine  is  not  a  serious  disease,  it  is  simply 
an  insidious  distortion  which  rarely  causes  more  than  compara- 
tively slight  discomfort.  It  is  usually  overlooked  in  the  incipient 
stage  when  it  might  be  checked  or  cured,  and  when  the  deformity 
finally  attracts  attention  it  is  often  no  longer  amenable  to  cor- 
rection. Under  these  circumstances,  with  the  uncertainty  that 
exists  as  to  the  ultimate  prognosis,  the  tediousness  of  treatment 
which  cannot  ofFer  the  assurance  of  definite  cure,  it  is  not  strange 
that  the  affection  is  not  one  for  the  treatment  of  which  any  con- 
siderable sacrifice  is  considered  essential. 

A  third  class  of  cases  would  include  the  fixed  deformity  in  older 
subjects,  many  of  whom  are  obliged  to  assume  in  their  occupations 
attitudes  that  predispose  to  deformity.  In  the  treatment  of  this 
class  a  support  to  relieve  discomfort  and  to  prevent  exaggerated 
distortion    may   be   essential. 


184  ORTHOPEDIC  SURGERY 

Thus,  there  are  three  classes  or  tj'pes  of  scoHosis  in  which 
distinct  methods   of  treatment  may  be  employed. 

1.  Curvatures  in  very  young  children,  in  which  forcible  cor- 
rection and  fixation  are  indicated  in  the  hope  of  correcting  the 
deformity  of  the  bones  and  curing  the  distortion. 

2.  The  milder  degrees  of  deformity  for  which  treatment  by 
exercises  and  if  possible  by  favoring  postures  is  that  of  selection, 
and  in  which  support  is  a  temporary  and  incidental  adjunct. 

3.  Fixed  deformity  in  older  subjects,  and  those  cases  caused  by 
disease;  as,  for  example,  by  paralysis,  by  empyema  and  the  like, 
for  which  constant  support  might  be  required. 

As  a  rule,  however,  no  absolute  therapeutic  distinction  can  be 
made,  and  treatment  by  exercises  and  by  postures  should  be 
employed  whenever  practicable  in  all  cases,  whether  supports  are 
used  or  not. 

Posture  and  Exercises. — ^'N^iatever  may  have  been  the  original 
cause  of  the  distortion  of  the  spine  and  whatever  may  be  its 
degree  it  is  more  marked  when  the  patient  is  fatigued.  Fatigue 
in  the  normal  individual  is  shown  by  the  increase  in  the  normal 
anteroposterior  curves;  fatigue  in  the  deformed  subject  causes  an 
increase  in  the  pathological  curves.  It  requires  far  more  mus- 
cular effort  to  hold  the  deformed  spine  in  the  best  possible  attitude 
than  to  hold  the  normal  spine  in  the  correct  posture.  Motion  in 
the  normal  spine  is  as  free  in  one  direction  as  in  another,  and  it 
simply  requires  a  proper  balancing  of  the  muscular  force  to  hold 
it  in  the  median  line.  But  when  there  is  a  fixed  deformity,  to 
overcome  which,  even  in  part,  requires  the  conscious  effort  of 
the  patient,  it  is  evident  that  on  the  relaxation  of  this  effort  the 
spine  will  sink  back  into  the  habitual  posture.  The  more  con- 
firmed the  deformity  the  greater  must  be  the  effort  to  overcome  it, 
and  the  more  rapidly  will  fatigue  be  manifest.  Fatigue,  or,  rather, 
the  relaxation  of  conscious  muscular  effort,  is  favored  by  attitudes 
that  do  not  require  the  balancing  action  of  the  muscles.  For 
example,  the  sitting  posture  during  school  hours  favors  deformity, 
while  the  constant  alternation  of  postures  in  work  or  play  that 
requires  muscular  activity  opposes  it.  Thus,  the  selection  of 
occupations,  or,  at  least,  the  restriction  of  the  time  passed  in 
inactive  postures,  ls  an  important  part  of  treatment. 

As  improper  attitudes  are  favored  by  weakness  of  muscles,  and 
as  the  maintenance  of  the  best  possil)le  position  requires  a  greater 
expenditure  of  muscular  force  than  is  required  in  the  normal 
individual,  the  strengthening  of  all  the  muscles  of  the  body,  and 


LATERAL    CURVATURE   OF   THE  SPINE  185 

particularly  of  those  of  the  back,  by  gymnastic  exercises,  even 
beyond  the  normal  standard,  is  the  most  important  indication  in 
treatment. 

One  of  the  most  effective  systems  of  treatment  of  lateral  curva- 
ture is  that  advocated  by  Teschner,  of  New  York.  On  the  theory 
that  lateral  curvature  is  induced  by  or  that  its  development  Is 
favored  by  a  general  lack  of  muscular  strength  and  lack  of  mus- 
cular control  and  co-ordination,  Teschner  urges  the  necessity  of 
the  systematic  cultivation  of  all  the  muscles  of  the  body  as  well 
as  those  of  the  trunk,  the  part  particularly  at  fault.  He  also 
insists  upon  the  importance  of  exercising  each  muscular  group  to 
the  point  of  fatigue  on  the  theory  that  a  muscle  cannot  be 
developed  to  its  full  capacity  unless  it  is  thoroughly  fatigued  by 
uninterrupted  automatic  contractions  and  relaxations.  The  term 
automatic  implies  that  the  patient  shall  be  so  thoroughly  trained 
in  the  rhythmical  movements  that  they  require  no  thought  for 
their  performance.  Thus,  ease  and  grace  may  replace  awkward- 
ness and  inco-ordination. 

The  system  advocated  by  Teschner  Ls  modified  from  one  taught 
by  Attilla,  a  "trainer  of  strong  men."  It  consists  of  a  series  of 
exercises  with  light  dumb-bells,  and  it  is  supplemented  by  so-called 
heavy  work.  The  exercises  are  designed  for  systematic  cultiva- 
tion of  all  the  muscles  of  the  body,  the  heavy  work  more  directly 
for  the  correction  of  the  deformity  of  the  spine. 

General  Exercises. — The  exercises  should  be  performed  before 
a  mirror,  the  patient  being  clad  in  a  close-fitting  rowing  suit,  so 
that  the  attitudes  may  be  constantly  observed  by  the  patient  and 
by  the  instructor.  The  greatest  attention  is  paid  to  the  perfection 
of  the  alternating  movements  of  the  limbs  in  order  that  they  may 
become  in  time  purely  automatic  in  character.  During  the  per- 
formance of  the  exercises  the  patient  holds  himself  in  the  best 
possible  position. 

These  exercises  were  described  and  illustrated  by  Teschner  in 
the  Aiinals  of  Surgery  for  August,  1S95,  from  which  they  are, 
with  his  permission,  reproduced. 

"A  pair  of  dumb-bells,  weighing  from  one-half  to  five  pounds 
each,  according  to  the  ability  of  the  patient,  is  used  in  a  series  of 
twenty-six  exercises. 

"The  Exercises. — The  patient  stands  erect,  the  heels  together, 
the  toes  apart,  the  knees  thoroughly  extended,  the  abdomen 
retracted,  the  chest  high,  the  head  well  poised,  and  the  patient 
looking  intently  and  sharply  into  his  or  her  own  eyes  in  the  mirror, 


186 


ORTHOPEDIC  SURGERY 


the  lips  being  evenly,  but  not  too  firmly,  closed,  and  the  facial 
muscles  ia  repose.  The  patient  should  breathe  easily  and  regu- 
larly while  exercismg  (Figs.  lOS  and  109). 


Fig.  lOS 


Fig.  109 


Fig.  110 


Fig.  112 


a-: 


"].  The  upper  extremities  are  fully  extended  downward,  the 
forearms  supinated,  the  elbows  remaining  close  to  the  sides  of  the 
body,  and  the  u[)per  arms  being  fixed;  the  forearms  are  alternately 
and  automatically  fully  flexed  and  extended,  the  wrists  and  entire 


LATERAL   CURVATURE   OF   THE  SPINE 


187 


body  being  fixed  and  immovable.  Twenty  to  fifty  times  (Fig. 
110). 

"2.  The  same  position  and  exercise,  except  that  the  forearms, 
are  fully  pronated,  and  remain  so  during  alternate  flexion  and 
extension.     Twenty  to  fifty  times   (Fig.   111). 

"3.  Both  bells  over  the  shoulders,  the  arms  abducted  at  right 
angles  to  the  body  and  in  the  same  vertical  and  horizontal  planes, 
the  forearms  fully  flexed  upon  the  arms,  and  the  wrists  fully 
flexed  upon  the  forearms.  The  forearms  and  wrists  are  then 
alternately  and  automatically  extended  and  flexed.  Ten  to 
twenty  times   (Fig.   112). 


Fig.  113 


Fig.  114 


i^-- 


"4.  The  same  position  and  exercises,  except  that  both  upper 
extremities  are  flexed  and  extended  at  the  same  time.  Five  to 
fifteen  times   (Fig.   113). 

"5.  Both  upper  extremities  fully  extended  forward  on  a  level 
with  the  shoulders,  the  dorsum  of  the  hands  outward.  They  are 
then  fully  and  forcibly  abducted  on  a  horizontal  plane,  the  patient 
at  the  same  time  raising  the  body  upon  the  toes,  and  are  then 
permitted  to  recede  to  the  original  position,  the  body  resting  on 
the  toes  and  heels,  the  elbows  and  wrists  still  rigid,  the  bells  not 
being  permitted  to  touch  as  they  approximate  each  other.'  Five 
to  ten  times    (Figs.   114  and   115). 

"6.  Bells  in  the  position  of  exercises  No.  3  and  No.  4.  The 
arms  are  fully  extended  alternately  above  the  head.  Ten  to 
twenty  times  (Fig.  116). 


188 


ORTHOPEDIC  SURGERY. 


"7.  Bells  in  front  of  the  thighs,  forearms  pronated,  and  bells 
alternately  raised  to  the  level  of  the  shonlders,  the  elbows  and 
wrists  being  fixed.     Ten  to  twenty  times  (Fig.  117). 


Fig.  115 


Fig.  116 


Fig.  117 


Fin.  118 


LATERAL    CURVATURE   OF  THE  SPLXE 


189 


"8.  The  arms  abducted  at  right  angles  to  the  body,  the  bells 
rotated  rapidly  and  forcibly  forward  and  backward,  the  elbows 
being  fixed.     Five  to  ten  times    (Fig.    118). 


Fig.  119 


Ftg.  120 


Fig.  121 


Fig.  122 


Fig.  123 


190 


ORTHOPEDIC  SURGERY 


"9.  The  arms  abducted  at'right  anglesto  the  body,  the  thumbs 
upon  one  ball  of  each  bell,  the  hands  circumducted  forward  from 
above  downward,  the  ball  upon  which  the  thumbs  rest  describing 
circles,  the  elbows  and  shoulders  being  fixed.  Five  to  ten  times 
(Fig.   119). 

"10.  The  same  as  No.  9,  the  hands  being  circumducted  back- 
ward.    Five  to  ten  times  (Fig.  119). 

"11.  The  bells  to  the  side.  Right  face  upon  left  heel,  then 
placing  the  foot  at  right  angles  to  right  foot  opposite  the  arch, 
the  knees  slightly  flexed,  the  right  hand  at  waist-line  against 
the  body,  the  bell  being  perpendicular.  Second  part  of  motion: 
strike  from  the  shoulder  to  level  of  the  face,  advancing  a  step 


Fig.  124 


Fig.  125 


upon  the  left  foot,  rapidly  extending  the  right  thigh  and  leg,  the 
right  foot  being  fixed  upon  the  floor,  and  quickly  back  to  position. 
Ten  to  fifteen  times  (Figs.  120  and  121). 

"12.  Exacdy  the  reverse  of  No.  11.     Ten  to  fifteen  times. 

"13.  Bells  extended  above  the  head,  palmar  surfaces  looking 
forward,  bending  down  to  tiie  floor,  the  knees  remaining  extended, 
and  return.     Five  to  fifteen  times  (Figs.  122  and  123). 

"14.  Bells  downward  at  the  sides,  raising  and  dropping  the 
shoulders.     Ten  to  twenty  times  (Fig.  124). 

"15.  Bells  downward  ut  the  sides,  flexing  the  sj)ine  laterally, 
first  to  the  right  an<l  then  to  the  left.  Ten  to  twenty  times  (Fig. 
125). 


LATERAL   CURVATURE   OF   THE  SPINE 


191 


"16.  Both  arms  are  extended  forward  to  about  forty-five 
degrees  and  abducted  at  about  the  same  angle,  then  forcibly 
crossed  in  front  of  the  chest,  causing  the  pectoral  muscles  to  con- 


FiG.  126 


Fig.  127 


Fig.  128 


Fig.  129 


tract  vigorously,  the  elbows  and  wrists  being  fixed,  and  then  back 
to  the  original  position.  Five  to  twenty  times,  alternating  tl;e 
right  and  left  hands  above  (Fig.   126). 


192 


ORTHOPEDIC  SURGERY 


"17.  Bells  at  the  sides,  palmar  surfaces  looking  forward. 
Extend  arms  backward  in  a  vertical  plane  as  forcibly  as  possible, 
holding  them  rigid  in  the  fully  extended  position  for  a  few  moments, 
and  then  returning  the  bells  to  the  sides.  Five  to  fifteen  times 
(Figs.  127  and  128). 

"IS.  Bells  to  the  sides.  Raise  the  body  upon  the  toes  and 
sink  to  the  -original  position.     Ten  to  twenty  times  (Fig.  129). 

"19.  Same  position.  Raise  the  toes  as  far  as  possible  from 
the  floor,  the  body  remaining  erect.  Ten  to  twenty  times  (Fig. 
130). 

"20.  Same  position.  The  patient  squats,  abducting  the  knees 
and  resting  upon  the  toes,  the  heels  being  raised,  the  trunk  per- 


FiG.  130 


Fig.  131 


fectly  erect,  then  resuming  first  position.  Five  to  twenty  times 
(Fig.   131). 

"21.  Same  position.  Standing  upon  left  foot.  Flexing  the 
right  thigh  to  a  right  angle  to  the  body,  extending  the  knee  and 
ankle  fully.  The  patient  s(|uats  on  the  left  ham,  the  left  heel 
remaining  on  the  floor,  and  then  resumes  the  first  position.  Two 
to  five  times  (Fig.  132). 

"22.  The  same  standing  upon  tl;e  right  foot.  Two  to  five 
times. 

"23.  The  same  position.  Alternately  and  forcibly  flexing  the 
thighs  and  legs,  causing  the  knees  to  tf)ucli  the  shoulders.  Ten 
to  twenty  times   (Fig.   133). 


LATERAL   CURVATURE   OF   THE  SPINE 


193 


"24.  The  same  position  as  in  No.  21,  extending  the  right 
lower  extremity,  the  right  bell  inside  the  thigh,  the  right  foot 
moved  in  a  circle  on  a  horizontal  plane  to  complete  extension 


Fig.  132 


Fig.  133 


Fig.  134 


Fig.  13.5 


.r^^ 


backward,  and  resuming  the  first  position.     Two  to  five  times 
(Figs.  134  and  135). 

"25.  The  same  as  No.  24,  standing  upon  tlie  right  foot.     Two 
to  five  times   (Figs.   134  and   135). 

13 


194 


OB T HOPE Die  S UR GEE Y 
Fig.   136 


"26.  The  patient  lying  supine  upon  the  floor,  the  lower 
extremities  fully  extended,  the  bells  resting  upon  the  chest,  then 
raising  the  trunk  to  the  sitting  position,  the  lower  extremities 


Fig.   137 


Scolioflia  of  an   advanced  type  accoinijaiiied  by  dyspniji'u  and  cyaiiotii.s.     (Tesclmer.) 


LATERAL   CURVATURE  OF  THE  SPINE 


]95 


remaining  extended,  and  the  eyes  being  fixed  upon  the  ceiling, 
and  returning  to  the  original  position,  touching  the  back  of  the 
head  only  on  the  floor;  thus  the  hyperextension  of  the  spine  is 
maintained.     Five  to  twenty  times  (Fig.  136)." 


Ihe  same  patient   swinging  3C-iJouiid  bell,  j^howiig   tlie   nuij^cular  d(.>\  elnpmenl. 

(Teschner). 


I  consider  these  floor  exercises  especially  useful,  and,  in  prac- 
tice, add  several  others  to  those  described  by  Teschner,  \'iz.: 

27.  The  patient  lying  as  in  Fig.  136,  lifts  each  fully  extended 
leg  alternately  a  distance  of  about  two  feet  from  the  floor,  then 
lets  it  slowly  sink  to  its  original  position.     Ten  times. 

28.  Both   limbs   together.     Five   times. 


196 


ORTHOPEDIC   SURGERY 


29.  The  patient  lying  extended  in  the  prone  position,  places 
the  palms  of  the  hands  on  the  hips  and  "looks  at  the  ceiling," 
overextends  the  spine  as  mnch  as  possible,  then  sinks  slowly  to 
the  original  position. 

30.  Each  leg  fully  extended  is  lifted  upward  alternately  as  far 
as  possible   (hyperextension  at  the  hips).     Ten  times. 


Fio.   139 


Fig.  140 


The  patient  pushing  25~pouri(l  hcll.s;   tlie 
right  arm  up.     (Teschnor.) 


'J  he  patient  jjushing  2.5  pound  bells;   the 
left  arm  up.     (Teschner.) 


31.  Hyperextension  at  both  hips  simultaneously  if  possible. 
Five  times. 

"When  the  patient  has  })ecome  proficient  in  these  exercises, 
they  sh(;uld  be  done  at  fiome  every  morning  and  evening. 


LATERAL   CURVATURE   OF  THE  SPINE  J 97 

"The  Heavy  Work. — Bells,  weighing  from  five  to  eighty 
pounds  each,  and  steel  bars  and  bar-bells,  weighing  from  twentv- 
six  to  over  one  hundred  and  eleven  pounds,  are  used  in  different 
ways.  Bells  are  pushed  from  the  shoulders  above  the  head  alter- 
nately as  often  as  the  patient  is  able  (Figs.  139  and  140). 

"The  patient  is  instructed  to  swing  a  heavy  l)ell  with  one  hand 
from  the  floor  above  the  head  and  down  again,  the  elbow  and 
the  wrist  being  fixed,  and  the  motion  repeated  as  often  as  possible 
in  a  systematic  manner;  then  with  the  other  hand  the  same  num- 
ber of  times  and  later  with  both.  This  exerts  all  the  extensor 
muscles  from  the  toes  to  the  head  in  rapid  succession." 

(For  this  exercise  the  patient  stands  firmly,  with  the  legs 
astride  of  the  heavy  bell,  and  then,  bending  over,  he  seizes  it  and 
throws  the  extended  arm  upward  entirely  by  the  action  of  tlie 
back  muscles.  The  bell  is  poised  for  a  moment  above  the  head, 
and  it  is  then  swung  downward,  carr;ying  the  extended  arm 
between  and  behind  the  legs.) 

"When  a  heavy  bell  is  pushed  or  swung  above  the  head  on 
the  side  opposite  the  scoliosis,  the  action  of  the  back  muscles,  to 
sustain  the  weight  and  equilibrium,  is  such  as  to  cause  the  curved 
spine  to  approximate  a  straight  line  (Fig.  140).  A  similar  result 
is  produced  when  a  heavy  weight  is  held  by  the  side  of  the  erect 
body  on  the  scoliotic  side,  the  arm  being  at  full  length. 

"When  a  heavy  bar  is  raised  above  the  head  with  both  hands 
the  patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  main- 
tain an  equilibrium.  This  necessitates  tl  e  bending  of  tl.e  head 
backward,  the  straightening  and  hyperextending  of  the  spine, 
and  consequently  correcting  a  faulty  position  with  a  weight  super- 
imposed. The  heavier  the  weight  put  above  the  head,  whetlier 
with  one  hand  or  with  two,  the  more  the  patient  must  exert  him- 
self or  herself  to  attain  and  maintain  a  correct  or  an  improved 
attitude  in  order  to  sustain  tl;e  equilibrium.  (By  an  improved 
attitude  I  mean  the  greatest  amount  of  correction  of  the  devia- 
tion of  the  spine  that  the  fixation  of  a  deformitv  will  allow.) 
Hence,  the  greater  the  weiglit,  the  more  forcible  the  actions  of 
the  muscles  become,  and  the  greater  the  temporary  reduction 
of  a  deformity.  It  is  by  means  of  frequent  and  forcible  tem])or- 
ary  reductions  of  deformities,  by  voluntary  muscular  action, 
that  we  can  hope  to  improve,  and  do  improve,  those  cases  which 
are  amenable  to  any  form  of  active  treatment. 

"When  a  patient,  lying  supine  upon  the  floor,  raises  a  heavy 
bar  above  the  head  so  that  the  arms  are  perpendicular  to  the 


198 


ORTHOPEDIC  SURGERY 


floor,  the  weight  of  the  bar,  the  position  and  weight  of  the  body, 
and  the  action  of  the  muscles  tend  to  broaden  the  entire  back 
and  shoulders,  and  a  slow  downward  movement  tends  to  -N^iden 
the  entire  chest,  and  most  markedly  at  the  shoulders.  The  fre- 
quent repetition  of  the  upward  and  downward  movements  plays 
an  important  part  in  the  rapid  development  of  the  chest  and 
back.  Pushing  the  bells  above  the  head,  swinging  them  with 
each  hand  separately  and  with  both  hands  together,  raising  a  bar 
above  the  head,  standing  and  h^ng  down,  and  the  exercises 
before  enumerated,  constitute  one  day's  work. 

Record  of  the  Work  Performed  by  a  Girl  Fourteen  Years 
OF  Age  (Teschner). 


50-lb.  bar  above  the 

Regu- 

Swinging 

head. 

Date, 

lar 
exer- 

Pushins: 
two  lO-lb, 

with  each 
hand  one 

SwiiiRins: 
with  both 

Pushing 

two  20-lb. 

1895. 

cises. 

bells. 

15-lb.  bell, 

hands  two 

bells. 

Lying 

Bells. 

right  to  let  t. 

15-lb.  bells. 

Standing. 

down. 

April  6 

3Jbs. 

'•      9 

100 

10-10 

5 

Instructed. 

Instructed. 

•'    11 

" 

150 
2  15-lb.  bells 

25-25 
120-lb  bell 

15 

10 

2 

5 

"     13 

" 

50 

25-25 

25 

12 

5 

10 

"     16 

«< 

54 

30-30 

35 

IS 

7 

12 

"     IS 

" 

60 

35-35 
1  25-1  b.  bell 

40 
2  20-lb.  bells 

20 

7 

15 

"    21. 

70 

20-20 

20 

30 

10 

15 

"    25 

90 

22-22 

25 

33 

15 

16 

"    27 

100 

35-35 

30 

50 

17 

20       ■ 

"    30 

110 

50-50 

35 

60 

20 

22 

May   2 

•' 

120 

60-60 

36 

70 

20 

25 

1  30-lb.  bell 

2  25-lb.  bells 

6  Mb.  bar 

64-lb.  bar 

"      4 

1' 

140 

2(1-20 

40 

25 

5 

10 

"      7 

" 

150 

25-25 

45 

30 

7 

12 

"     14 

<< 

160 

27-27 

50 

34 

9 

13 

"     16 

" 

170 

30-30 

65 

40 

10 

14 

"As  the  amount  of  work  performed  by  a  patient  depends 
upon  the  last  previous  record  of  that  patient,  that  record  must  be 
improved  upon  at  each  succeeding  visit,  unless  there  be  a  good 
reason  to  the  contrary.  Most  patients  can  well  stand  three 
treatments  a  week  (vide  table).  In  mild,  habitual  cases  im- 
provement in  deportment  is  noticed  by  the  patient's  relatives 
and  friends  and  by  the  patients  themselves  within  the  first  two 
weeks.  In  these  cases  two  months'  treatment  usually  suffices  to 
effect  a  'complete'  cure.  In  the  more  severe  cases  such  rapid 
results  cannot  be  expected,  but  a  certain  appreciable  improvement 
is  efi'ected,  and  the  amount  of  improvement  depends  upon  the 
persistent  continuance  of  the  treatment.  When  there  is  fixed 
rotation  of  long  standing,  with  bony  and  ligamentous  changes, 
the  prospect  is  not  as  good;  but  even  in  those  cases  consider- 
able improvement  will  be  evident." 


LATERAL    CURVATURE   OF   THE  SPINE  199 

"Patients  are  not  permitted  to  wear  supports  of  any  kind,  not 
even  corsets.  They  should  not  exercise  until  at  least  two  hours 
after  a  meal,  nor  when  menstruating.  The  general  health  is 
improved  by  the  exercises;  the  patients  gain  in  height  and 
weight.  The  girth  and  breadth  measurements,  chest  depth, 
strength  tests,  and  lung  capacity  are  generally  increased,  and  the 
depth  of  the  abdomen  is  usually  decreased.  In  some  cases,  es- 
pecially those  of  undersized  patients,  the  increase  in  height  is 
very  rapid,  and  it  is  certainly  more  than  th.e  increase  by  ordinary 
growth.  There  were  marked  cases  of  flat  foot  which  were  bene- 
fited. The  flat  feet  became  shorter  through  the  exercises  by  the 
increase  in  depth   of  the  inner  arches." 

This  system  of  exercises  combines  the  forcible  correction  of 
deformity  and  the  overcoming  of  restriction  of  normal  motion  by 
means  of  the  "heavy  work"  with  muscle  building.  It  has  the 
merit  also  of  making  an  immediate  mental  impression  upon  the 
patient  which  no  other  system  can  make;  for  if  the  patient  does 
not  "strain  every  nerve"  he  must  certainly  exercise  every  muscle 
to  preserve  the  equilibrium  while  supporting  the  heavy  weights, 
and  this  mental  impression  is,  undoubtedly,  one  of  the  important 
elements  in  successful  treatment. 

The  system  has  the  disadvantage,  if  disadvantage  it  may  be 
called,  of  making  class  work  impossible,  for  the  patient  must  be 
under  constant  supervision,  not  only  that  he  may  be  urged  to 
the  limit  of  his  capacity,  but  that  overstrain  may  be  avoided  as 
well. 

It  might  appear  from  the  description  that  the  danger  of  over- 
work is  great,  but  in  a  long  series  of  cases,  some  of  which  were 
complicated  by  defects  of  the  heart  and  lungs,  no  unfavorable 
symptoms  have  been  observed  by  Teschner.  The  system  is, 
however,  one  that  can  only  be  practised  by  a  physician. 

Another  system  of  exercises,  modified  somewhat  from  the 
so-called  Swedish  system,  more  suitable  for  class  work  is  that 
followed  at  the  Hospital  for  Ruptured  and  Crippled.  Dr.  Truslow 
has  outlined  for  me  some  of  the  more  important  exercises,  and 
illustrated  them  with  the  photographs  that  are  reproducetl  here. 

The  objects  of  the  treatment  are:  (1)  To  overcome  the  patient's 
faulty  habits  of  posture  by  the  repeated  purposeful  assumption 
of  proper  postures;  in  other  words,  to  counteract  the  deformity 
habit  by  training  the  mental  and  muscular  perception  of  symmetry. 
(2)  To  stimulate  and  to  strengtlien  the  weakened  muscles,  par- 
ticularly those  muscular  groups  that   are   especially  concerned  in 


200 


ORTHOPEDIC  SrRGEBY 


overcomino-  the  deformities,  and  which,  for  the  present  purpose, 
may  be  considered  as  weak. 

For  convenience  of  description  the  exercises  are  di^^ded  into 
two   classes:     (1)    self-correction;    (2)    muscle   building. 


Fig.  141 


Typical  lateral  curvature.      RiKlit  dorHal.     Left  luriibiir. 


LATERAL   CURVATURE   OF   THE  SPINE  201 

Self -correction ;  Postures. — The  first  exercises  (a  and  h)  in  self- 
correction  are  for  the  purpose  of  overcoming  the  anteroposterior 
deformities  that  usually  accompany  lateral  deviation  of  the  spine. 

(a)  Head  Bending  Backward. — In  this  exercise  the  chin  is 
not  tilted  upward,  but,  the  head  being  held  level,  the  neck  is 
drawn  directly  backward  until  the  cer^-ical  and  upper  part  of  the 
dorsal  segments  of  the  spine  are  completely  extended.  Thus, 
by  increasing  the  distance  between  the  points  of  attachment  of 
the  sternomastoids  and  the  scaleni,  strong  traction  is  made  upon 
these  muscles  with  the  effect  of  elevating  the  upper  part  of  the 
thorax — an  important  feature  in  the  exercise. 

(6)  Trunk  Bending  Forward  and  Trunk  Raising. — The 
patient  stands  in  the  erect  posture  with  the  spine  extended  and 
the  chest  expanded  as  in  the  previous  exercise.  The  trunk  is 
then  bent  forward  (similar  to  Fig.  146),  the  only  motion  being 
at  the  hip-joints.  The  trunk  is  then  raised  again  to  the  former 
position,  care  being  taken  to  keep  the  hips  farther  back  than  the 
chest.  In  both  flexion  and  extension  the  spine  must  be  rigidly 
held  in  the  corrected  attitude,  and  there  must  be  no  motion  at  the 
knees.  There  is,  of  course,  a  movement  corresponding  to  exten- 
sion at  the  ankle-joints  when  the  legs  and  buttocks  are  thrown 
backward  to  compensate  for  the  forward  bending  of  the  body. 
The  object  of  this  exercise  is  to  train  the  patient  to  keep  the  hips 
back  and  the  chest  forward. 

The  other  exercises  in  self-correction  are  for  the  purpose  of 
overcoming  lateral  deviation  of  the  spine,  the  right  tlorsal,  left 
lumbar  curve  being  taken  as  the  type   (Fig.   141). 

This  series  is  arranged  in  a  progression,  and  each  one  must  be 
learned  before  the  next  in  order  is  attempted. 

(c)  Left  Neck  Firm. — The  left  hand  is  placed  behind  the 
neck,  the  left  shoulder  is  raised,  and  the  left  elbow  is  held  well 
back.  This  posture  impresses  upon  the  patient  the  necessity  of 
approximating  the  left  shoulder  and  the  neck  (Fig.  142), 
I  (rf)  Body  Inclination  to  the  Left. — This  is  a  most  impor- 
tant posture;  it  is  intended  to  correct  mechanically  the  faulty 
inclination  to  the  right  and  to  overcome  the  upper  curve  by  trac- 
tion on  its  concavity.  The  patient  holding  the  arm  in  the  first 
position  is  instructed  to  stretch  well  out  Avith  the  left  elbow, 
rotating  upward  and  abducting  the  left  scapula  as  much  as  pos- 
sible. This  puts  upon  the  stretch  the  rhomboidei  and  the  lower 
half  of  the  trapezius  of  the  left  side,  thus  making  strong  traction 
upon  their  points  of  attachment  in  the  dorsal  concavity.     At  the 


202 


ORTHOPEDIC  SUE GEM Y 


same  time  the  patient  is  directed  to  sway  the  pehis  to  the  right. 
This  usually  requires  assistance  at  first,  for  it  brings  into  action 
certain  deep  back  muscles,  over  which  one  has  ordinarily  but 
little  control.     The  shoulders  must  be  kept  level  and  the  proper 


Fig.  142 


Left  neck  firm. 


relation  of  the  head  and  neck  to  the  left  shoulder  must  not  be 
disturbed  in  this  forced  .stretch  to  the  left  (Fig.  143). 

(e)  Chest  Pressing  with  the  Right  Hand. — The  patient 
holding  the  left  arm  in  the  first  position  presses  the  right  hand 
firmly  against  the  dorsal  convexity.     This  posture  may  be  em- 


LATERAL   CURVATURE   OF  THE  SPINE 


203 


ployed  to  advantage  if  there  is  a  long  right  dorsal  cun'e,  when  it  is 
an  efficient  aid  to  the  left-sided  pull  of  the  two  former  exercises. 
(/)  Right  Neck  Fikm. — The  right  hand  is  placed  behind  the 
neck,  without,  however,  disturbing  tlie  improved  position  induced 
by  the  first  exercises.     With  both  hands  placed  behind  the  head. 


Fig.  143 


Body  inclin:itii)n  to  the   left. 

the  arms  being  in  a  symmetrical  position,  there  is  better  mechani- 
cal fixation  of  the  head,  neck,  and  upper  part  of  the  trunk  during 
the  next  exercise  (Fig.   144). 

{g)  Left  Hip  Twisting  Backward. — In  posture  {d)  the 
pelvis  was  swayed  slightly  to  the  right;  it  is  now  twi.sted  slightly 
backward  on  the  left  side  to   overcome   the  twist  in  the  lumbar 


204 


ORTHOPEDIC  SURGERY 


spine  which  usually  throws  this  side  of  the  pehis  somewhat  for- 
ward. This  correcting  motion  should  be  carried  out  in  the  lower 
dorsal  and  lumbar  segments,  and  it  should  not  affect  the  attitude 
of  the  remainder  of  the  trunk. 

(/?)  Left  Oblique  Stride  Standing. — ^The  pehac  twist  and 
right-sided  sway  being  rigidly  maintained,  the  left  foot  is  placed 
about  two  foot-lengths  forward  and  a  little  outward.     Upon  this 

Fig.  144 


llighl  lieck  firm. 


leg  the  greater  j)art  of  the  weight  of  the  body  in  now  supported 
This  allows  a  slight  downward  tilt  of  the  pelvis  to  the  right,  and 
lessens  the  left  lumbar  convexity  (Fig.  145).  The  positions, 
attained  by  the  progressive  exercises  to  this  point,  being  main- 
tained, the  patient  continues  with — 

{i)  Trunk  Bending  Forw^ard. — In  this  posture,  motion  takes 
place  in  the  hip-joints  only,  as  in  the  first  exercise.     This  exer- 


LATERAL   CURVATURE  OF  THE  SPINE  205 

cise  further  emphasizes  the  symmetrical  position  of  the  head  and 
neck,  the  left-sided  inchnation  of  the  upper  half  of  the  trunk, 
the  right-sided  inchnation  of  the  lower  half,  the  twist  and  down- 

FiG.  145 


Left  oblique  stride  standing. 


206 


ORTHOPEDIC  SURGERY 


ward  tilt  of  the  pehas  (Fig.  146).  The  return  to  the  improved 
standing  position  should  be  made  in  this  order:  (1)  trunk  raising; 
(2)  replacement  of  the  left  foot;  (3)  return  of  both  arms  to  the 


Fig.  146 


Trunk  bending  forward. 

sides.     This  is  done  slowly  and  carefully  by  the  patient,  who 
attempts   to   maintain   the   improved    posture. 

The  postures  constitute  a  progression  which  cannot  be  learned 
in  less  than  seven  treatments;  often  much  more  time  is  required. 
As  each  part  is  learned  it  should  be  practised  at  home  until  the 


LATERAL   CURVATURE  OF  THE  SPINE  207 

next  treatment,  when  a  new  posture  is  added,  if  it  appears  that 
progress  can  be  made. 

These  successive  postures  are  in  reality  exercises  in  that  it 
requires  constant  muscular  effort  to  retain  them,  but  they  are  not 
exercises  in  the  sense  of  repeated  alternations  of  position.  The 
series  is  simply  an  elaboration  of  what  is  called  the  keynote 
posture.  The  raising  of  the  left  elbow,  for  example,  makes  it 
easier  for  the  patient  to  overcome  the  distortion  of  the  upper 
part  of  the  spine;  it  also  instructs  him  in  the  manner  of  holding 
the  spine  in  the  improved  position  after  the  arm  is  placed  by  the 
side. 

The  same  is  true  of  all  the  postures ;  each  one  suggests  and  makes 
correction  easier,  and  after  sufficient  practice  the  patient  should 
be  able  to  assume  the  corrected  position  without  placing  the  arm 
or  the  leg  in  the  preliminary  attitude.  Thus  the  successive 
postures  are,  as  it  were,  letters,  which,  placed  together  one  by 
one,  make  a  complete  word,  or  the  best  possible  position  that  the 
patient  can  assume.  At  first  the  patient  must  use  the  letters  and 
slowly  spell  out  the  corrected  attitude,  but  after  the  muscles  have 
been  educated  by  the  repeated  assumption  of  each  posture,  and 
when  the  perception  of  symmetry  has  been  acquired,  the  corrected 
attitude  may  be  assumed  at  will.  Finally,  the  improved  posture 
will  be  instinctively  retained,  and  will  become  habitual. 

Muscle  Building  Exercises. — In  the  treatment  of  lateral  curvature 
one  aims  to  strengthen : 

1.  The  posterior  cervical  muscles. 

2.  The  dorsal  and  lumbar  muscles. 

3.  The  muscles  of  vertebroscapular  attachment. 

4.  The  abdominal  muscles. 

5.  The  thigh  and  leg  muscles. 

6.  The  chest  expanding  muscles. 

The  following  exercises  have  been  selected  as  best  adapted  for 
this  purpose.  Each  one  should  be  performed  five  or  more  times 
according  to  the  strength  of  the  patient. 

(a)  Opposite  Standing,  Head  Bending  Backward,  Re- 
sisted.— ^The  patient  stands  before  a  wall  or  a  shoulder-high  hori- 
zontal bar,  on  which  the  hands  are  placed  with  the  arms  extended. 
The  head  is  bent  forward,  and  is  then  forced  backward,  the  latter 
movement  being  resisted  by  the  hand  of  the  surgeon.  This 
exercise  is  designed  to  strengthen  the  posterior  cervical  muscles. 

(6)  Opposite  Bend  Standing,  Trunk  Raising,  Resisted. — 
The  patient  stands  with  the  upper  part  of  the  thighs  in  contact 


208 


ORTHOPEDIC  SUBQEBY 


\\'ith  a  table  or  horizontal  bar.  The  hands  are  placed^behind  the 
neck  and  the  body  is  bent  forward  on  the  hip-joints  as  in  the 
first  exercise.     The  surgeon,  standing  behind,   places  his   right 


Fig.   147 


"0|Jl)(>.sil(;  l»(;ii(l  sruiKliiiK,"  Iruiik  raising,  lesisl-cd. 

hanrl  over  the  post(!rior  dorsal  j)roniiiieiice  and  his  left  over  the 
lumbar  projection.  The  patient  then  raises  the  trunk  to  the  erect 
position    against   the   combined    resistance    (Fig.    147).     With   a 


\LATERAL  CURVATURE   OF  THE  SPINE  209 


14 


2 10  ORTHOPEDIC  SVBGEB Y 

little  practice  the  surgeon  learns  to  give  an  outward  twisting 
motion  to  his  hands  while  resisting,  which  tends  to  untwist  the 
spinal  rotations.  ^Mien  the  dorsal  rotation  to  the  right  is  marked 
this  untwisting  may  be  facilitated  by  encircling  the  patient's  chest 
with  the  left  hand,  while  with  the  right,  strong  forward  and  out- 
ward pressure  is  made  as  the  patient  raises  the  body.  This  exer- 
cise is  for  the  purpose  of  developing  the  muscles  of  the  erector 
spinse  group. 

(c)  Proxe  Lying,  Head  and  Shoulder  Raising  "the  Seal." 
— The  patient  lies  upon  a  table  or  upon  the  floor,  and  raises  the 
head  and  chest — "looks  at  the  ceiling."  Progression  is  made 
in  the  increased  leverage  of  arm-weight  transference. 

1.  With  the  hands  on  the  backs  of  the  thighs. 

2.  ^Yith  the  left  hand  behind  the  neck  and  the  right  hand  on 
the   back   of   the   thigh. 

3.  With  both  hands  behind  the  neck,  and  with  the  elbows 
well  out  and  back. 

4.  "Swimming."  The  arm  motions  of  swimming,  in  three 
counts.  This  exercise  is  to  strengthen  the  muscles  of  the  back 
from  the  head  to  the  pelvis. 

(d)  Prone  Lying,  "Diving." — The  patient  lies  upon  a  table 
the  trunk  and  pelvis  projecting  beyond  its  edge,  the  limbs  being 
fixed  by  a  strap  or  by  the  weight  of  another  person.  The  body 
is  then  bent  downward  and  is  raised  again  to  the  horizontal  posi- 
tion (Fig.  148).  In  this  exercise  assistance  will  be  required 
at  first.  Progression  is  made  by  transference  of  arm  weights,  as 
in  the  former  exercise,  thus: 

1.  With  the  hands  on  the  hips. 

[    2.  With  the  arms  stretched  out  at  right  angles  to  the  body. 

3.  With  the  hands  behind  the  neck. 

4.  With  the  arms  extended  in  the  line  of  the  body. 

This  exercise  is  for  the  purpose  of  strengthening  all  the  muscles 
of  the  back. 

(e)  Prone  Lying,  Leg  Raising. — The  patient,  lying  in  the 
prone  posture  upon  the  floor  or  table,  lifts  the  limbs  (overextends) 
alternately,  the  raised  leg  held  perfectly  straight.  When  the  left 
thigh  Ls  extended,  as  much  as  the  iliofemoral  ligament  will  allow, 
the  left  side  of  the  pelvis  is  tilted  upward  also,  thus  untwisting 
the  lumbar  spine.     Progression  in  this  exercise  is  made  as  follows : 

1.  Alternate  leg  raising,  unresisted. 

2.  Ahernate  leg  raising,  resisted. 

3.  The  leg  motions  of  swimming  in  three  counts. 


LATERAL  CURVATURE  OF  THE  SFJNE  211 

In  this  exercise  the  entire  lower  extremities  must  project  be- 
yond the  supporting  table.  The  exercises  are  for  the  purpose  of 
strengthening  the  lumbar  muscles  and  the  extensors  of  the  thigh. 

(/)  Opposite  Sitting,  Backward  Bending  of  the  Trunk. — 
The  patient  is  seated  upon  a  bench,  and  the  feet  are  fastened  to 
the  floor.  The  trunk  being  held  in  a  position  of  complete  exten- 
sion, is  bent  slowly  backward,  motion  being  at  the  hip-joint  only. 
Progression. 

1.  With   the   hands   behind   the   hips. 

2.  With  the  left  hantl  behind  the  neck,  the  right  hand  on  the 

hip. 

3.  With   both   hands   behind   the   neck. 

4.  With  both  arms  extended  upward. 

At  first  the  body  is  bent  backward  about  forty-five  degrees,  later 
until  the  head  touches  the  floor.  This  exercise  is  to  strengthen 
the  abdominal  muscles. 

(g)  The  Horizontal  Bar.  "Pull-ups." — The  patient 
hangs  by  the  hands  and  is  assisted  to  "chin  the  bar."  The  body 
is  then  allowed  to  sink  slowly  back  into  the  former  position,  the 
elbows  are  held  well  back,  and  the  patient  is  instructed  to  bear 
as  much  of  the  weight  as  is  possible  with  the  left  arm  and  shoulder. 
This  exercise  corrects  the  dorsal  curve  by  means  of  muscular 
activity,  and  the  lumbar  curve  by  the  weight  of  the  suspended 
pelvis  and  limbs.  The  muscles  used  are  those  with  vertebro- 
scapula   attachment. 

(h)  Left  Leg  Standing,  Pelvis  Tilting. — The  patient 
stands  upon  the  edge  of  a  bench,  supporting  the  weight  on  the 
left  leg,  the  right  leg  being  suspended  beyond  the  side  of  the 
bench.  While  the  head  and  trunk  are  kept  in  the  corrected 
position,  the  pelvis  is  made  to  tilt  sharply  downward  on  the  right, 
by  lowering  the  right  leg,  while  the  left  is  kept  perfectly  stiff 
This  has  the  effect  of  straightening  the  lumbar  curve. 

(i)  Left  Leg  "Hopping." — Both  hands  are  placed  behind 
the  neck  and  the  weight  is  supported  entirely  upon  the  ball  of 
the  left  foot.  Li  this  attitude  the  patient  hops  ten  or  more  times. 
This  exercise,  like  the  last,  tends  to  straighten  the  spine  and  to 
strengthen  the  muscles  of  the  left  leg,  which  are  often  somewhat 
weakened  from  disuse. 

(;)  Respiratory,  Half  Reclining,  Arm  Extensions  and 
Flexions,  Resisted. — ^The  patient  sits  in  a  chair  with  an  inclined 
back,  or  lies  upon  a  low  table  with  hard  pillows  under  the  mid- 
dorsal  region,  so  that  the  upper  doi-sal  and  cervical  segments  of 


212 


ORTHOPEDIC  SURGERY 

Fig.  149 


Lateral  curvature. 
Fig.  150 


'J'he  Harnc  patient,  whowirix  fixed  rotation  to  tin;  lij^lit,  in  the  tlioracic  region.    (See  I'iKK.  1.51 
and  152,  illuHtrating  a  simple  corrective  exercise  that  may  be  carried  out  by  the  patient.) 


LATERAL  CURVATURE  OF  THE  SPINE 

Fir;.  151 


213 


The  patient  shown  in  Figs.  149  and  150  inclines  the  body  to  the  right,  pressing  the  projecting 
ribs  in  with  the  right  hand.      (See  Fig.  152.) 


Fic.  1.52 


In  the  posture  shown  in  Fig.  151,  the  patient  inclines  the  body  forward.    The  correction 
is  illustrated  by  comparison  with  Fig.  150  in  the  same  position. 


214  OR THOPEDIC  SUBGEB  T 

the  spine  must  be  overextended.  The  arms  are  stretched  upward 
and  backward,  and  the  hands  are  grasped  by  the  surgeon,  who 
stands  behind  and  resists  the  patient's  downward  pull.  With  the 
upward  stretch  of  the  arms  and  pull  by  the  surgeon  the  patient 
inhales  forcibly.  With  the  downward  pull  against  resistance 
the  patient  exliales  forcibly.  This  exercise  is  made  in  the  rhythm 
of  slow  breathing. 

AMien  the  patient  has  been  thoroughly  instructed  in  self- 
correction  and  in  the  exercises  for  muscle  building,  general  gym- 
nastics for  systematic  motor  training  may  be  given  effectively 
to  groups  of  fifteen  or  twenty  pupils. 

The  exercises  illustrated  on  pages  186-194  will  serve  this 
purpose    satisfactorily. 

These  two  systems  of  treatment  by  gymnastics  have  been 
selected  as  the  most  practicable  of  the  many  that  have  been  de- 
vised. It  may  be  stated  that  any  treatment  that  makes  the  spine 
more  flexible,  that  overcomes  faulty  attitudes,  and  that  streng- 
thens the  muscles,  must  be  of  benefit  to  the  patient,  the  degree 
of  benefit  corresponding  to  the  persistence  and  energy  of  the 
pupil  and  the  instructor  rather  than  to  any  particular  theory 
on  which  such  treatment  is  based.  The  rotation  of  the  vertebral 
bodies  is  increased  by  forward  bending  of  the  trunk,  and,  as  this 
is  the  more  important  element  of  lateral  curvature,  it  is  evident 
that  extension  or  overextension  of  the  spine,  combined  with  lateral 
twisting  in  such  a  manner  as  to  reverse  the  habitual  inclination, 
will  most  directly  lessen  or  correct  the  distortion.  If  improvised 
exercises  are  conducted  from  this  standpoint  they  will  always  be 
effective  (Figs.  151  and  152). 

The  Removal  of  Superincumbent  Weight. — ^The  removal  of  super- 
incumbent weight  by  the  assumption  of  the  reclining  posture 
whenever  the  patient  is  fatigued  is  an  important  adjunct  in  the 
treatment  of  a  certain  class  of  cases.  The  patient  should  lie, 
preferably,  upon  a  hard  support  in  the  supine  posture,  with  the 
arms  extended  above  the  head.  If  the  dorsal  kyphosis  is  exag- 
gerated, a  firm  cushion  between  the  shoulders  or  under  the  pro- 
jecting ribs  will  aid  to  expansion  of  the  chest  and  favor  the  cor- 
recticm  of  the  deformity. 

Self-suspension. — Self-suspension,  by  means  of  the  halter 
and  pulley,  is  of  service  in  overcoming  secondary  contractions  of 
the  tissues,  and  thus  it  aids  in  the  correction  of  deformity.  It 
is  often  efficacious,  also,  in  relieving  the  discomfort  that  is  some- 
times a  troublesome  symptom  when  the  distortion  is  extreme. 


LATERAL  CURVATURE  OF  THE  SPINE 


215 


While  the  patient  Ls  suspended  forcible  manual  correction  of  the 
deformity   can    be   applied   to    advantage. 

Suspension  from  the  horizontal  bar  acts  in  a  similar  manner, 
although  it  is  less  effective  than  when  the  traction  is  made  upon 


Fig.  153 


Fig.  154 


Self-suspension,  illustrating  the  effect  of  traction  in  lessening  deformity  induced 
by  paralysis.     (Gibney.)     In  such  cases  support  is  essential. 

the  entire  spine.  In  this  form  of  suspension  the  bar  should  be 
oblique  in  direction,  the  high  side  for  the  low  shoulder.  Thus, 
a  passive  "keynote"  is  induced  while  the  patient  is  suspended. 
Exercises  in  this  position,  for  example,  flexion,  extension,  and 


216  OR THOPEDIC  SURGERY 

abduction  of  the  thighs,  swaying  the  trunk  from  side  to  side, 
"chinning"  the  bar,  and  the  Hke,  are  useful. 

The  Use  of  Braces  or  Other  Supports. — In  the  treatment  of  the 
ordmarv  type  of  lateral  curvature,  when  there  is  an  opportunity 
for  proper  systematic  gymnastic  training,  direct  support  is  not 
usually  indicated.  There  are,  however,  cases  even  in  this  class 
in  which  the  deformity  habit  is  so  persistent,  and  in  which  the 
voluntary  efforts  of  the  patient  to  assume  a  better  attitude  are 
so  ineffective,  that  support  may  be  employed  for  a  time  with 
advantage. 

The  best  support  is  a  plaster  corset  applied  with  as  much  manual 
corrective  force  as  is  practicable  while  the  patient  is  suspended  in 
the  upright  posture  if  lateral  deviation  is  most. marked  or  if  the 
curvature  is  flexible;  in  the  horizontal  preferably  if  the  rotation 
is  the  prominent  feature  of  the  deformity. 

If  correction  is  attempted  in  the  horizontal  attitude  the  patient 
may  be  suspended  in  the  prone  posture  on  a  strip  of  cotton  cloth 
rthe  hammock  method).  As  this  sinks  under  the  weight  the 
trunk  falls  into  the  attitude  of  overextension,  which  is  that 
most  favorable  for  the  untwisting  of  the  rotated  spine.  When 
the  deformity  is  marked,  the  body  may  be  suspended  in  the  lat- 
eral attitude  by  means  of  a  sling  of  cotton  cloth  passed  about  the 
prominent  ribs;  thus  the  weight  of  the  body  acts  as  a  correcting 
force  during  the  application  of  the  corset. 

i  In  using  such  corrective  force  one  endeavors,  if  possible,  to 
overcorrect  the  habitual  deformity  and  the  less  marked  changes  in 
the  anteroposterior  contour  as  well.  For  example,  if  the  lumbar 
region  is  flat  one  attempts  to  reproduce  the  normal  lordosis,  and 
if  the  body  is  habitually  inclined  in  one  direction  one  endeavors 
to  sway  it  to  the  opposite  side,  and  to  efface  the  so-called  high  hip. 

This  attitude  of  overcorrection  assured  by  the  corset,  combined 
with  exercises,  is  especially  efficacious  from  the  curative  stand- 
point in  the  treatment  of  single  flexible  curves.  If  the  second  or 
compensatory  curvature  has  already  appeared,  one  attempts  to 
overcorrect  the  primary  deformity  and  directs  exercises  for  the 
purpose  of  straightening  the  second  curve  while  the  patient  is 
wearing  the  corrective  corset.  For  as  the  compensatory  curva- 
ture is  usually  in  the  dorsal  region,  it  may  be  considerably  influ- 
enced by  postures  of  the  arms  and  shoulders.  As  often  as  pos- 
sible during  th(!  day  the  patient  should  endeavor  to  improve  upon 
the  attitude  wliicli  the  corset  enforces,  by  assuming  the  keynote 
position  and   by   flexing  and   extending  the   trunk  at  the  hips. 


LATERAL  CURVATURE  OF  THE  SPINE 


217 


For  general  exercises  the  corset  may  be  removed,  and,  as  a  rule, 
it  need  not  be  worn  at  night,  although  in  the  treatment  of  young 
subjects  its  constant  use  for  one  or  more  weeks  is  of  service  in 
enforcing  a  proper  attitude. 

"When  the  deformity  is  dependent  upon  irremediable  injury  or 
disease,  such,  for  example,  as  anterior  poliomyelitLs  or  empyema, 
some  form  of  brace  must  be  employed  constantly  to  prevent  exces- 
sive lateral  deviation  of  the  trunk;  and  in  cases  of  fixed  deformity 
in  older  subjects,  especially  if  the  patient's  occupation  Is  fatiguing, 
a  support  may  be  indicated  to  relieve  symptoms  of  discomfort  or 
pain. 

Support  is  employed  primarily  with  the  aim  of  preventing  an 
increase  of  deformity  and  to  relieve  symptoms  incidental  to  the 

Fig.  155 


The  Knight  spinal  brace,  as  used  in  lateral  curvature.  A  leather  or  canvas  band,  made 
adjustable  by  lacings,  is  stretched  from  the  posterior  upright  to  the  side  bar  on  the  side  of 
the  dorsal  convexity. 

deformity.  It  may  serve,  also,  in  some  degree  as  a  corrective 
appliance.  If  it  holds  the  spine  in  the  extended  position  or 
induces  lordosis,  it  may,  by  relieving  the  anterior  portion  of  the 
column  in  part  from  the  deforming  influence  of  superincumbent 
weight,  induce  or  permit  a  slight  lessening  of  the  rotation  of  the 
vertebral  bodies.  On  this  principle  a  light  steel  brace,  after  the 
Taylor  model,  may  be  as  effective  as  any  of  the  more  complicated 
appliances,  as  was  suggested  many  years  ago  by  Judson.  Corsets 
of  other  material  than  plaster,  for  example,  of  paper,  or  of  alumi- 
num, as  suggested  by  Phelps,  may  be  employed  when  the  de- 


218 


OR THOPEDIC  SURGERY 


fonnity  is  fixed  and  when  no  change  in  the  position  or  size  of 
the  trunk  is  to  be  expected.  The  Kjiight  brace,  when  carefully 
adjusted,  appears  to  meet  the  requirements  fairly  well,  and  when 
less  support  is  needed  an  ordmary  corset  strengthened  by  light 
steels  may  be  sufficient. 

Forcible  Correction  of  Deformity. — In  the  treatment  by  gymnas- 
tic exercises  the  patients  are  supposed  to  overcome  by  voluntary 

effort,  as  far  as  is  possible,  the 
^^°'  ^"^  secondary  accommodative  con- 

tractions of  the  soft  parts  that 
prevent  the  correction  of  the 
deformity,  the  heavy  work  of 
the  Teschner  system  being  par- 
ticularly effective  for  this  pur- 
pose. But  in  many  instances 
the  voluntary  correction  of  de- 
formity may  be  supplemented 
with  advantage  by  the  employ- 
ment of  force.  For  example, 
the  patient  may  use  the  weight 
of  the  body  as  a  means  of 
correction  by  forcibly  flexing 
the  trunk  over  a  padded  bar 
(Fig.  162),  and  a  variety  of 
similar  postures,  either  active 
or  passive,  with  or  without 
suspension,  may  be  utilized 
with  the  same  object.  Correc- 
tive force  applied  by  the  hands, 
the  patient's  trunk  being  flexed 
and  rotated  in  the  directions 
opposed  to  the  deformities, 
although  the  most  effective 
method,  is  the  most  fatiguing, 
and  machines  have  been  con- 
structed with  the  aim  of  apply- 
ing the  force  in  a  similar  manner.  This  is  illustrated  by  the 
appliance  of  Hoft'a,  which  has  been  modified  by  Schede  and 
others.  In  this  machine  the  patient  is  suspended,  the  hips 
are  fixed,  and  the  pressure  screws  are  applied  upon  the  con- 
vexities of  the  double  curve,  with  the  aim  of  untwisting  the 
spine.     The  correction  is  maintained  for  fifteen  minutes  or  longer. 


Forcible  correction  by  means  of  the  modified 
Hoffa  appliance.  (Bradford  and  Brackett). 


LATERAL  CURVATURE  OF  THE  SPINE  219 

and  it  is  then  followed  by  the  regular  exercises  of  the  day 
(Fig.  156). 

The  Forcible  Correction  of  Deformity  Combined  with  Fixation. — 
Forcible  correction  and  fixation  in  the  improved  position  is  the 
treatment  of  selection  for  resistant  lateral  curvature  in  early 
childhood,  because  one  cannot  command  the  co-operation  of  the 
patient  in  maintaining  the  proper  attitude,  and  because  the  rapid 
growth  at  this  age,  which  favors  the  increase  of  the  deformity, 
is  equally  favorable  to  its  cure  if  the  static  conditions  can  be 
changed. 

For  example,  one  treats  the  severe  rhachitic  kyphosis  of  in- 
fancy by  fixation  on  the  stretcher  frame  in  the  attitude  of  over- 
extension, and  by  daily  manual  correction  of  the  deformity. 
And  in  the  treatment  of  older  children,  in  whom  posterior  or 
lateral  deformity  is  fixed,  one  is  justified  in  using  the  same  method 
for  its  relief  and  cure  that  would  be  employed  in  the  treatment  of 
Pott's  disease.  In  this  class  the  plaster-of-Paris  jacket,  applied 
while  the  trunk  is  held  in  the  best  possible  position,  is  the  treat- 
ment of  selection — a  treatment  that  should  be  continued  until 
the  deformity  is  cured  or  until  further  rectification  by  this  means 
is  found  to  be  impossible. 

The  most  convenient  method  of  applying  the  jacket  is  by  means 
of  the  ordinary  suspension  apparatus.  The  back  having  been 
carefully  padded  at  the  points  of  pressure,  the  patient  is  sus- 
pended, and  while  traction  and  manual  corrective  force  are  ex- 
erted the  plaster  bandages  are  applied.  In  this  correction  two 
points  are  of  especial  importance:  to  attain  as  much  extension  or 
overcorrection  as  possible,  and  to  sway  the  entire  body  in  the 
direction  opposite  to  the  habitual  inclination.  By  overextension 
one  removes  the  weight  in  part  from  the  vertebral  bodies  that 
are  primarily  deformed,  and  by  lateral  correction  one  endeavors 
to  change  the  relation  of  the  weight  to  the  distorted  part.  This 
improved  position  must  be  carefully  maintained  by  the  hands 
until  the  plaster  bandages  have  become  firm.  The  jackets  may 
be  changed  at  intervals  of  about  a  month,  and  at  each  applica- 
tion one  attempts  to  improve  upon  the  former  position. 

Lovett^  has  urged  the  importance  of  correcting  anteroposterior 
deformities  by  straightening  the  compensatory  curves.  For 
example,  if  a  dorsal  convexity  is  accompanied  by  a  lumbar  con- 
cavity the  jacket  should  be  applied  while  the  lumbar  segment  is 
straight.     This  may  be  accomplished  by  supporting  the  trunk  in 

^  Transactions  American  Orthopedic  Association,  1901,  vol.  xiv. 


220  ORTHOPEDIC  SURGERY 

the  prone  posture  on  a  hammock,  the  legs  hanging  downward  on 
either  side,  or  in  the  sittmg  posture.  The  effect  of  flexion  of 
the  thighs  in  straightening  the  himbar  spine  is  ilhistrated  in 
Fig.  157.  Theoretically,  if  this  attitude  persists,  it  should 
induce  a  flattening  of  the  abnormal  kyphosis  of  which  the  lordo- 
sis is  the  effect,  particularly  if  the  improved  position  is  favored 
by  appropriate  postures  and  exercises. 

In  the  cases  m  which  corrective  force  is  employed  the  jacket 
is  used  in  preference  to  the  corset,  because  it  holds  the  spine 
more  perfectly.  It  is,  of  course,  a  disadvantage  to  employ  such 
restraint,  but,  as  has  been  stated,  the  prognosis  in  fixed  rotary 
lateral  curvature  in  a  young  child  is,  as  regards  ultimate  deform- 

FiG.  157 


Congenital  scoliosis.     After  treatment  for  three  years  by  forcible  correction  and 
fixation  by  plaster  jackets.     Showing  the  disappearance  of  the  rotation. 

ity,  extremely  unfavorable,  and  one  is  justified,  therefore,  in 
sacrificing  muscular  activity  in  order  that  the  original  deformity 
of  the  bones  may  be  remedied.  As  an  illustration  of  persistence 
in  this  method  of  treatment,  it  may  be  stated  that  it  was 
continued  by  me  for  nearly  five  years  in  one  case  of  extreme 
scoliosis  of  congenital  origin,  with  most  gratifying  success 
(Fig.  157). 

The  jackets  may  be  applied,  also,  in  the  horizontal  position, 
traction  being  exerted  upon  the  arms  and  legs,  combined  with 
manual  pressure  on  the  trunk,  somewhat  after  the  manner  of  the 
Calot  method  of  correction  of  the  deformity  of  Pott's  disease. 
Or  the  body  may  be  supported  by  a  sling  or  other  aj)pliance.  In 
certain  instances  one  is  able  to  correct  the  deformity  more  effect- 


LATERAL  CURVATURE  OF  THE  SPINE  221 

ually  by  horizontal  than  by  vertical  suspension  in  the  manner 
already  described. 

When  the  deformity  has  been  overcome,  or  when  the  contin- 
uation of  the  treatment  seems  undesirable,  the  jacket  may  be 
replaced  by  a  corset,  which  may  be  removed  for  daily  massage  and 
for  exercises.  This  may  be  finally  discarded  when  the  muscular 
strength  has  been  regained. 

As  has  been  stated,  forcible  correction  and  fixation  Ls  essen- 
tially a  treatment  of  deformity  in  early  childhood.  But  in  cer- 
tain instances,  when,  for  example,  the  deformity  is  extreme  or  is 
increasing  rapidly,  it  may  be  employed  in  adolescence.  In  the 
treatment  of  this  class  of  cases  the  plaster  jacket  is  usually  applied 
while  the  patient  is  fixed  in  the  best  possible  position  by  means  of 
some  form  of  pressure  apparatus,  as  Ls  illustrated  in  Fig.  156. 

Forcible  correction  of  deformity  in  this  manner,  under  anaes- 
thesia, with  subsequent  fixation  of  the  trunk  and  of  the  head,  if 
possible,  in  the  overcorrected  position,  is  advocated  by  Wullstein,^ 
and  it  may  be  of  service  in  certain  cases. 

The  Volkmann  Seat. — In  cases  of  primary  lumbar  curva- 
ture, or  when  the  secondary  curve  of  this  region  is  pronounced, 
the  attitude  may  be  improved  and  the  deformity  may  be  cor- 
rected in  part  by  seating  the  patient  on  an  inclined  plane,  the 
high  side  beneath  the  low  hip,  thus  lessening  the  convexity  of 
the  curve. 

The  High  Shoe. — The  same  object  may  be  attained  in  the 
erect  posture  by  the  use  of  a  higher  heel,  or  heel  and  sole.  The 
elevation  may  be  from  a  half-inch  to  an  inch  and  a  c^uarter,  the 
amount  being  regulated  by  'its  effect  upon  the  contour  of  the 
trunk. 

Posture  and  Support  during  Recuivtbency. — The  atti- 
tudes habitually  assumed  during  recumbency  should  be  investi- 
gated. The  bed  should  be  provided  with  a  hard  mattress  and  a 
low  pillow,  and  the  patient  should  be  encouraged  to  lie  habitually 
upon  the  side  which  opposes  the  deformity,  or  upon  the  back. 
The  rectification  induced  by  such  an  attitude  may  be  still  further 
increased  by  the  use  of  a  hard  pillow  beneath  the  convexity  or 
beneath  the  back,  and  in  certain  instances  the  Barwell  sling  may 
be   employed   with   advantage. 

General  Treatment. — The  importance  of  improving  the  gen- 
eral condition  of  the  patient  by  regulation  of  the  diet,  by  cold 
baths,  and  by  active  exercise  in  the  open  air  is  self-evident.     The 

1  Zoit.  f.  Orthop.  Chir.,  1902,  Bd.  x.,  H.  2. 


222  Olt THOPEDIC  SUBGEBT 

strain  upon  the  back  should  be  lessened  by  providing  proper 
seats  and  by  limiting  the  time  passed  in  passive  attitudes,  and  by 
lessening,  as  far  as  possible,  the  restraint  of  the  clothing.  These 
precautions  are  of  almost  equal  importance  with  the  active  treat- 
ment. 

The  Duration  of  Treatment. — The  duration  of  treatment  depends, 
of  course,  upon  the  character  of  the  deformity  and  upon  its  causes. 
In  the  ordinary  type  of  adolescent  scoliosis  the  duration  of  active 
treatment  is  usually  from  three  to  six  months.  In  this  time  the 
muscles  may  be  so  strengthened  and  the  necessity  for  constant 
attention  to  the  attitudes  may  be  so  impressed  upon  the  patient 
that  the  simple  exercises  which  may  be  performed  at  home  may 
be  sufficient.  In  such  exercises  the  most  important  postures  are 
those  which  hyperextend  the  spine.  The  constant  effort  should 
be  to  make  motion  in  one  direction  as  free  as  in  another,  and  to 
practice  postures  that  tend  to  reduce  deformity.  In  all  cases  it 
is  well,  if  possible,  to  keep  the  patient  under  supervision  during 
the  period  of  growth. 


CHAPTER   IV. 

DEFORMITIES   OF    THE    SPINE    (Continued).     DEFORMITIES    OF 
THE  CHEST.     THE  FUNCTIONAL  PATHOGENESIS 
OF  DEFORMITY. 

Variations  in  the  Contour  of  the  Spine. 

One  recognizes  a  certain  contour  of  the  spine  as  normal,  but 
there  are  variations  from  this  type  which,  within  certain  Hraits, 
can  hardly  be  classed  as  abnormal.     Two  of  these  have   been 


Fig.  1.58 


Fig.  159 


:^ 


The  hollow  round  back.     (Stafel.) 


The  round  back.     (Stafel.) 


mentioned:  the  round  hack  (Fig.  159),  in  which  there  is  a  gen- 
eral forward  droop  most  marked  at  the  shouldei-s,  antl  the  hollow 


224  ORTHOPEDIC  SURGERY 

round  back  (Fig.  158),  in  which  the  dorsal  kyphosis  and  the  him- 
bar  lordosis  are  somewhat  exaggerated.  A  third  type  is  the 
flat  back  (Fig.  90),  in  which  there  is  neither  a  lumbar  lordosis  nor 
a  dorsal  kyphosis.  In  the  marked  cases  there  is  an  actual  promi- 
nence in  the  lumbar  region,  while  the  scapulae  project  backward, 
overhanging  the  flattened  dorsal  spine.  This  type  of  back  is  the 
result,  in  many  instances,  of  a  rhachitic  kyphosis  which  was  most 
prominent  in  the  lumbar  region,  and  it  often  follows  a  primary 
lateral  rotation  of  the  lumbar  vertebrae.  The  flat  back  and  the 
rcund  back  predispose  to  lateral  curvature.  Deviations  from 
the  normal  contour  of  the  spine  are  attended  by  a  change  in  the 
inclination  of  the  pelvis  and  in  the  relation  of  the  support  of  the 
limbs  and  trunk.  The  round  back  (Fig.  159)  is  almost  always 
indicative  of  weakness,  and  it  is  often  accompanied  by  other 
postural  deformities,  especially  often  by  weak  feet. 

Anteroposterior  Deformities  of  the  Spine. 

Kyphosis. — As  has  been  stated  in  the  chapter  on  Pott's  disease, 
the  spine  is  practically  straight  at  birth.  If  during  the  early 
weeks  of  life  an  infant  be  placed  in  the  sitting  posture  the  head 
falls  forward  and  the  spine  bends  into  a  long  posterior  curve, 
the  posture  of  weakness.  The  normal  anterior  convexity  of  the 
cervical  section  is  established  when  the  gain  in  muscular  power 
enables  the  infant  to  hold  the  head  erect,  and  that  of  the  lumbar 
region  w^hen  the  pelvis  is  tilted  downward  by  the  extension  of 
the  thighs   in  the  erect  posture. 

In  the  erect  posture  the  constant  tendency  of  the  weight  of  the 
head  and  of  the  thoracic  and  abdominal  organs  is  to  draw  the 
spine  forward  and  to  re-establish  the  original  posterior  curve. 
This  tendency  is  resisted  by  the  action  of  the  posterior  muscles 
of  the  trunk.  AMienever,  therefore,  the  muscular  power  is  les- 
sened or  the  body  is  overburdened,  or  whenever  the  spine  is 
weakened  by  disease,  the  tendency  toward  the  original  curve  of 
weakness  becomes  apparent  (Fig.  160).  Thus,  the  causes  of  an 
abnormal  increase  in  the  posterior  curvature  of  the  spine  are"  very 
numerous.  It  is,  as  has  been  stated,  the  characteristic  attitude 
of  weakness,  as  is  illustrated  in  infancy  and  in  old  age.  It  is 
one  of  the  common  occupation  deformities  of  adult  life;  it  is  a 
common  postural  deformity  of  childhood  and  adolescence.  It 
may  be  induced  by  a  variety  of  diseases  that  lessen  the  resistance 
of  the  spine  or  that  interfere  with  its  function.     For  example, 


DEFORMITIES  OF  THE  SPINE 


225 


by   rhachitLs,   spondylltLs    deformans,   osteitis    deformans,   Pott's 
disease,  and  affections  of  a  similar  nature. 

The  kyphosis  of  rhachitLs  i.s  most  marked  in  the  lower  re- 
gion, that  of  spondylitis  deformans  may  involve  the  entire  spine, 
while  the  simple  postural  curvature  is  most  marked  in  the  upper 
dorsal  region — "round  shoulders."  In  a  number  of  the  postural 
deformities  the  increase  in  the  dorsal  kyphosis  is  balanced  by  an 
increased  lordosis,  and  in  this  form  there  is  simply  an  exaggera- 


FiG.   160 


Marked  posterior  cui  vatuie  of  the  spine  apparently  induced  by  weakness  incidental 

to  illness. 

tion  of  the  normal  curves  of  the  spine — the  "hollow  round" 
back.  In  other  instances  there  is  a  general  forward  droop  of 
the  trunk  in  which  the  lumbar  lordosis  may  be  lessened;  this 
form  is  more  common  in  childhood — the  "round"  back. 

The  forms  of  kyphosis  that  are  the  direct  result  of  disease 
have  been  described  elsewhere.  Postural  kyphosis — "round 
shouldere" — is  one  of  the  common  deformities,  and  in  childhood 
its  etiology  is  similar  to  that  of  lateral  curvature,  of  which  it  jnay 

15 


226 


OB  THOPEDIC  SVRGERY 


be  a  predisposing  cause.  Round  sliouldei-s  and  the  accompany- 
ing flat  chest  may  be  induced  also  by  obstructions  in  the  respira- 
tory passages,  such  as  enlarged  tonsils,  adenoids,  and  the  like, 
or  by  bronchitis  or  heart  disease.  Another  predisposing  cause 
is  clothing  that  prevents  the  full  expansion  of  the  chest  and  the 
extension  of  the  arms,  and  even  the  weight  of  clothing  suspended 
from  the  shoulders  may  be  a  factor  in  the  etiology.  These  and 
other  possible  contributing  causes  should  be  investigated  in  all 
cases  of  this  character. 

A  marked  type  of  deformity  is  sometimes  seen  in  adolescents 
(Fig.    161),   induced   apparently   by   posture   and   by  overwork. 


Fig.    161 


'.Posterior  curvature  of  tlie  spiiiu  m  .Ml'iN  -rcniij  wiili  ligitlity.     A 
be  mistaken  for  that  of  spondylitis  deformans. 

although  in  most  instances  it  may  he  assumed  that  a  slighter 
deformity  of  long  standing  serves  as  a  predisposing  cause.  In 
this  type  the  deformity  is  resistant,  and  there  is,  as  a  rule,  pain 
or  discomfort  most  marked  in  the  lumbar  region. 

Treatment. — The  importance  of  correcting  even  slight  poste- 
rior curvatures  of  the  spine  which  directly  interfere  with  the  proper 
expansion  of  the  chest  and  which  when  more  extreme  may 
induce  disarrangement  or  displacement  of  the  internal  organs  is 
evident. 


DEFOIIMITIES  OF  THE  SPINE 


227 


The  treatment  is  similar  to  that  of  lateral  curvature.  The 
assumption  of  the  military  attitude,  with  the  head  erect,  the  chin 
depressed,  the  shoulders  thrown  back,  the  chest  expanded,  and 
the  abdomen  retracted,  should  be  encouraged.  And  those  ex- 
ercises that  expand  the  chest  and  that  strengthen  the  muscles 
of  the  upper  part  of  the  spine  are  especially  important.  (Such 
exercises  are  illustrated  by  Figs.  105,  106,  113,  114,  119,  120 
129,  135,  137,  139,  162,  and  163.)  If  the  range  of  vertical  ex- 
tension of  the  arms  is  limited,  this  restriction  must  be  overcome 


Fig.  lf)2 


Fig.  103 


Exercises  for  the  correction  of  posterior  curvatures  of  the  spine.     (Hoffa.) 


before  the  deformity  of  the  spine  can  be  permanently  improved. 
In  well-marked  cases  the  patient  should  be  encouraged  to  read 
or  study  in  the  pi-one  posture;  in  this  attitude,  in  which  the  trunk 
must  be  supported  upon  the  elbows  and  the  head  held  backward, 
there  is  necessarily  an  involuntary  correction  of  the  deformity. 
In  certain  instances  a  light  spinal  brace  or  corset  may  be  employed 
during  the  hours   when  the  passive  attitude  must  be  assumed 


228 


ORTHOPEDIC  SUROEBT 


(Fig.  164).  Shoulder  braces,  so-called,  are  useless,  because 
the  lumbar  lordosis  is  increased  when  the  shoulders  are  drawn 
backward.  Clothing  should  not  restrict  the  movements  of  the 
arms  or  trunk,  and  as  little  weight  as  possible  should  be  suspended 
from  the  shoulders.  In  the  more  extreme  cases,  in  which  the 
k\-phosis  is  of  long  duration  and  rigid,  forcible  correction  after 
the  Calot  method  may  be  indicated  as  a  preliminary  treatment. 
Fixed  support,  preferably  the  plaster  corset,  is  employed  until  the 
patient  has  become  accustomed  to  the  new  attitude.  Afterward 
treatment  by  exercise  and  posture  is  continued  as  in  the  ordinary 


Fig.   164 


lempered  steel  uprights  for  round  shoulders.      (Bradford  and  Lovett.) 

type.  Whenever  a  patient  is  under  treatment  for  deformity  of 
the  trunk  the  attempt  should  be  made  to  restore  the  proper  rela- 
tion of  the  body  and  limbs,  and  thus  to  restore  the  general  sym- 
metry of   the   body. 

Lordosis. — Lordosis,  or  an  abnormal  hoUowness  of  the  back, 
Ls  far  less  common  than  kyphosis.  It  is  not  a  simple  postural 
deformity,  but  it  is  usually  secondary  to  disease  or  deformity 
either  of  the  spine  or  of  the  adjoining  members.  For  example, 
lordosis  may  be  induced  by  flexion  contraction  of  the  thighs; 
it  Ls  a  symptom  of  congenital  displacement  of  the  hips;  it  is 
sometimes  a  result  of  certain  forms  of  nervous  disease,  in  which. 


CONGENITAL  ELEVATION  OF  THE  SCAPULA 


229 


because  of  muscular  weakness,  the  body  Ls  swayed  backward  to 
retain  the  balance,  as  in  the  muscular  dystrophies.  Lordosis 
in  the  lumbar  region  may  be  a  compensation  for  a  kyphosis  in 
the  upper  segment.  It  is  caused  directly  by  spondylolisthesis. 
It  may  be  a  congenital  deformity,  and  it  is  said  to  be  a  peculiarity 
of  contortionists. 

Treatment. — As  lordosis  is  usually  a  secondary  deformity  its 
treatment  would  be  included  in  the  treatment  of  its  causes.  In 
some  instances  the  discomfort  which  is  usually  present  when  the 
deformity  is  well-marked  may  be  relieved  by  a  proper  corset 
sufficiently  strong  to  support  the  back. 

Congenital  Elevation  of  the  Scapula. 

Synonym.— Sprengel's  deformity. 

Sprengel's  deformity  is  a  congenital  elevation  of  the  scapula 
above  the  level  of  its  fellow,  an  elevation  accompanied  in  most 


Fig.  165 


CoiiKeiiital  elevation  of  the  right  .scapular;  with  the  arm  elevated  the  scapular  is  in  contact 
with  the  occiput,  as  is  indicated  by  the  deep  fold;  age  of  the  patient  three  months. 

instances  by  rotation,  so  that  its  lower  angle  is  brought  nearer  to 
the  spine  while  its  upper  border  projecting  above  the  clavicle 
has  in  several  instances  been  mistaken  for  an  exostosis  (Fig.  165). 
The  cervical  muscles  passing  to  the  scapula  are  shortened  aiid 
changed  in  direction.  Thus,  its  mobility  is  lessened  and  the  range 
of  vertical  extension  of  the  arm  is  restricted.  The  deformity 
may  be  combined  with  torticollis  or  with  cervical  ribs  or  defective 
formation  of  the  spine  for  example,  absence  of  vertebrii?  or  rhachis- 
chisis.     In  many  instances  there  is  an  accompanying  lateral  curva- 


230 


ORTHOPEDIC  SURGERY 


tiire  of  the  spine,  the  convexity  being  usually  toward  the  deformed 
side.  And  not  infrequently  the  posterior  border  of  the  scapula  is 
attached  to  one  or  more  of  the  lower  cer^^cal  vertebras  by  a  bony 
growth.  Ninety-nine  cases  have  been  collected  from  literature  re- 
c:ntly  by  Zesas/    Forty-seven  were  of  the  right  side,  thirty-six  of 

Fig.   166 


Congenital  elevation  of  the  scapiilar  of  a  moderate  degree  in  adolescence. 


the  left,  and  in  eleven  both  scapulae  were  elevated.  Of  eighty- 
two  cases  forty-eight  were  in  males. 

The  deformity  was  first  described  by  Eulenburg^  but  in  more 
detail  by  Sprengel/  who  reported  four  cases  in  children  from  one  to 
seven  years  of  age. 

Etiology. — The  etiology  is  doubtful,  but  in  many  instances  it 
appears  to  be  the  result  of  a  constrained  position  of  the  foetus. 
In  two  of  Sprengel's  cases,  seen  soon  after  birth,  the  arm  appeared 
to  have  been  fixed  behind  the  back  of  the  cliild. 

It  is  of  interest  to  note  that,  according  to  Chievitz,  the  upper 
limb  is  in  its  origin  a  cervical  appendage,  retaining  an  elevated 


1  Zeits.  f.  Orth.  Chir.,  Band  xv.,  Heft  1,  1905 

2  Archiv  f.  klin.  Chir.,  1868. 


!<  Ccntralbl.  f.  Chir.,  1895. 


CERVICAL  RIBS  231 

position  during  foetal  life,  and  that  interference  with  its  descent 
by  constraint  or  otherwise  may  explain  the  etiology. 

Congenital  elevation  of  the  scapula  may  be  simulated  by  the 
distortion  and  muscular  atrophy  resulting  from  birth  palsy,  or 
even  by  certain  cases  of  rotary  lateral  curvature  in  which  the 
scapula  is  elevated  and  prominent. 

Treatment. — If  the  case  is  seen  in  childhood  and  if  the  contrac- 
tion of  the  vertebroscapula  muscles  is  extreme,  the  shortened 
tissues  may  be  divided  by  open  incision  as  in  torticollis,  and  if 
the  scapula  is  joined  to  the  spine  the  bony  process  should  be  re- 
moved. In  older  subjects  no  treatment  other  than  that  for  the 
lateral  curvature  is,  as  a  rule,  indicated. 

The  Absence  of  Vertebrae. 

Absence  of  vertebrae  is  usually  associated  with  rhachischisis. 
Several  cases,  however,  have  come  under  my  observation  in 
which  there  was  absence  of  vertebrae  without  other  malforma- 
tion. In  two  of  the  cases  the  deficiency  was  in  the  cer\acal 
region,  in  the  others  in  the  lumbar.  The  noticeable  shortness 
of  the  affected  section  of  the  spine  was  the  only  symptom. 

Cervical  Ribs. 

Cervical  ribs  are  not  uncommon.  Forty-six  cases  are  reported 
by  Riesman.^  The  rib  may  be  complete,  articulating  with  the 
sternum,  or  incomplete,  connected  by  ligament  with  the  sternum 
or  first  rib,  or  it  may  be  simply  an  elongated  transverse  process. 
In  most  instances  the  anomaly  is  bilateral. 

If  the  ribs  are  complete  the  neck  appears  wide  and  short  and 
the  projecting  ribs  may  be  felt  as  bony  prominences  (Fig.  167). 

The  subject  is  of  surgical  interest  because  a  number  of  cases 
have  been  reported  in  which  pressure  on  the  nerves  and  blood- 
vessels induced  pain  and  even  paresis  of  the  arm  and  feeble 
circulation.  Such  symptoms,  as  a  rule,  do  not  appear  until  ado- 
lescence or  adult  life.  The  treatment  is  resection  of  that  portion 
of  the  rib  that  causes  pressure. 

Absence  of  Ribs. — Absence  or  defective  formation  of  ribs  is 
uncommon.  In  such  cases  there  is  usually  defective  formation  of 
the  corresponding  muscles,  and  lateral  curvature  of  the  spine  i^ 
often  present. 

1   Univ.  of  Penna.  Bulletin,  Marcli.  1904. 


232  ORTHOPEDIC  SURGERY 

Defective  Formation  of  the  Pectoral  Muscles. — Several 
instances  in  whicli  one  or  both  of  the  pectoral  muscles  were 
defective  or  absent  have  been  observed  at  the  Hospital  for 
Ruptured  and  Crippled.  The  malformation  in  these  cases  caused 
no  direct  s;\TQptoms.^ 

Absence  or  Defect  of  the  Clavicle. — Thirty-eight  cases  of  de- 
fective formation  of  the  clavicle  on  one  or  both  sides  are  recorded,^ 
In  most  instances  a  portion  of  the  sternal  extremity  is  present. 
The  defect  appears  to  cause  but  slight  inconvenience. 

Deformities  of  the  Chest. 

The  Flat  Chest.— The  so-called  fiat  chest  is  an  accompani- 
ment of  the  round  back  (Fig.  159).  In  most  instances  the  chest  is 
not  actually  flattened  in  the  sense  that  its  anteroposterior  diameter 
is  diminished.  It  appears  flatter  because  the  shoulders  and 
scapulae  are  displaced  forward. 

Woods  Hutchinson  has  called  attention  to  the  fact  that  the 
so-called  flat  chest  is  usually  a  round  chest,  in  the  sense  that  it  is 
actually  deeper  than  the  normal,  a  persistence  of  the  foetal  type. 
He  suggests  that  such  persistence  may  be  one  of  the  causes  of 
so-called  round  shoulders,  the  round  chest  affording  no  adequate 
support  for  the  scapulae. 

Hutchinson^  has  presented  an  index  showing  the  relative  depth 
of  the  chest  at  different  ages,  illustrating  the  progress  from  the 
keel  chest  of  the  lower  orders  to  the  bellows-shape  of  the  adult 
human  form.  This  index  is  found  by  dividing  the  anteroposterior 
diameter  at  the  nipples  by  the  transverse  diameter  at  the  same 
level;  hence  the  lower  the  index,  the  longer  and  flatter,  more 
bellows-like  the  chest. 

Fcetal  index     ..........  103 

Infantile  index          .........  87 

Child 90 

Adult 72 

Treatment.— The  treatment  of  the  so-called  flat  chest  is  similar 
to  that  of  the  round  shoulders,  with  which  it  is  often  combined — 
that  is,  by  exercises  conducted  with  the  special  object  of  improv- 
ing the  strengtli  of  the;  muscles  of  the  back  and  increasing  the 
expansion  of  the  upjKT  part  of  the  chest.     The  importance  of 

'    Marlireni'',  Revue  d'CJrthopc'die,  May,  1903. 

2  Klar,  Zeits-  f.  Orth.  Chir.,  Hd-  xv.,  Heft  2,  1900. 

3  Journal  American  Medical  Association,  September  11,  1897. 


DEFORMITIES  OF  THE  CHEST 


233 


correcting  the  deformity,  which  interferes  with  the  proper  expan- 
sion of  the  hings  and  thus  predisposes  to  disease,  should  be  evident. 


Pigeon  Chest.     Synonym. — Pectus  cariuatum. 
The  pigeon,  or  keel-shaped,  chest  resembles  the  quadrupedal 
type  in  tliat  the  anteroposterior  is  increased  at  the  expense  of  the 


234 


ORTHOPEDIC  SUB  GEE Y 


lateral  diameter.  The  sternum  is  thrust  forward  and  downward 
like  the  keel  of  a  boat,  the  lateral  compression  being  most  marked 
at  the  junction  of  the  ribs  and  the  cartilages.  This  deformity  is 
almost  always  acquired  (Fig.  168);  it  is  usually  an  effect  of  rha- 
chitis,  and  it  is  described  under  that  heading.  It  may  be  in- 
duced by  obstruction  of  respiration  caused  by  enlarged  tonsils 
and  the  Hke,  if  this  is  present  at  an  early  age.     It  may  be  a  second- 

FiG.  16S 


General  rhachitic  distortions  and   pigeon  chest. 


ary  efl'oct  of  the  .sinking  forward  and  downward  of  the  upper 
half  of  tlie  tnmk,  as  in  Pott's  disease  of  the  middle  of  the  spine. 
Treatment. — The  treatment  of  secondary  deformity  would  be 
included  in  the  treatment  of  the  affection  of  which  it  is  the  result. 
Manif)iilati()n,  massage,  and  breatliing  exercises  may  be  employed 
in  the  treatjn(;nt  of  sim})le  pigeon  chest.  The  tendency  is  toward 
spontaneous  cure;  it  is  rarely  seen  in  adult  life. 


DEFORMITIES  OF  THE  CHEST 


235 


The  Funnel  Chest.     Synonym. — Pectus  excavatum. 

This  deformity  (Fig.  169)  is  the  reverse  of  the  pigeon  chest. 
The  sternum  is  depressed  and  the  lateral  diameter  of  the  thorax 
is  correspondingly  increased.  The  milder  types  of  the  affection 
in  which  there  are  one  or  more  depressions  or  hollows  in  the 
sternum  are  common.     The  extreme  form,  in  which  the  entire 


Fig.   169 


Pectus  excavatum.     This  patient  has  ocular  torticollis  also. 


sternum  is  depressed,  is  rare.  It  is  practically  always  a  congenital 
deformity,  and  it  is  not  susceptible  to  direct  treatment. 
Minor  Deformities  of  the  Chest. — As  has  been  stated,  distor- 
/  tions  of  the  chest  secondary  tt)  deformity  of  the  spine  are  often 
discovered  before  the  original  cause  is  suspected.  And  the  impor- 
tance of  the  various  minor  irregularities  of  the  chest  or  in  the 
direction  of  the  ribs  when  once  discovered  is  often  exaggerated. 


236  ORTHOPEDIC  SURGERY 

They  are  usually  the  result  of  preceding  rhachitis.  The  increase 
of  the  capacity  of  the  chest  by  appropriate  exercises  aids  in  the 
correction  of  asymmetry. 

Scapular  Crepitus. 

Loud  creaking  or  grating  sounds  induced  by  the  movement  of 
the  scapula  on  the  thorax  sometimes  appear  without  apparent 
cause  or  are  developed  by  exercises  during  the  treatment  of  lat- 
eral curvature.  The  causes  are  apparently  bony  irregularities, 
bursse,  and  the  like.     Twenty-two  cases  are  reported  by  Kuttner.^ 

Acquired  Luxation  or  Subluxation  of  the  Clavicle. 

Partial  displacement  of  the  sternal  end  of  the  clavicle  is  not 
particularly  uncommon.  In  some  instances  it  is  caused  by  injury; 
in  others  no  cause  can  be  assigned.  Most  often  there  appears  to 
be  a  laxity  of  the  capsular  ligament  that  allows  a  displacement 
during  certain  movements  of  the  arm.  The  displacement  is 
readily  reduced,  but  the  weakness  and  insecurity  may  cause  dis- 
comfort and  disability. 

Treatment. — In  some  instances  the  displacement  may  be  pre- 
vented by  the  pressure  of  a  pad  and  truss  spring,  attached  behind 
to  the  corset  or  braces  and  passing  over  the  shoulder  close  to  the 
neck.  Such  an  appliance  is  especially  useful  if  the  displacement 
occurs  at  certain  times  only,  as  in  dressing  the  hair,  playing  on 
the  violin,  etc.  Cures  are  reported  as  the  result  of  the  injection 
of  alcohol  into  the  joint  from  time  to  time,  and  Wolffs  has  oper- 
ated with  success  as  follows:  The  joint  is  opened  by  a  straight 
incision.  A  fragment  of  bone  is  detached  from  the  clavicle  above 
and  a  similar  one  from  the  sternum;  these,  still  adherent  to  the 
periosteum,  are  overlapped  in  front  of  the  joint  and  the  capsule 
is  then  sutured.  As  a  rule  the  affection  is  not  of  particular 
importance. 

Asymmetrical  Development. 

In  normal  individuals  there  is  often  a  slight  difference  between 
the  two  halves  of  the  body,  and,  as  is  well  known,  inequality 
in  the  length  of  the  legs  is  not  at  all  uncommon.     Inc(iuality  of 

>   Deutach.  med.   WochenHchrift,  June  23,  1904. 
'^  Centralbl.  f.  Chir.,  November  30,  1893. 


ASYMMETRICAL  DEVELOPMENT 


237 


the  two  halves  of  the  body  may  be  congenital,  and  it  may  be 
evident  at  birth,  but  usually  it  does  not  attract  attention  until 
adolescence.  In  many  instances  this  inequality  is  a  slight 
atrophy,  the  result  of  a  cerebral  hemiplegia  of  early  childhood. 
In  other  instances  the  inequality  may  be  due  to  congenital  hyper- 


FiG.   170 


Hypertrophy  of  the  right  forearm  and  hand,  due  to  congenital  ntevus. 


trophy  that  may  affect  the  entire  limb.  In  such  cases  the 
enlargement  may  be  due  to  an  abnormal  amount  of  normal  tissue, 
but  in  most  instances  the  hypertrophy,  which  becomes  more 
marked  with  the  growth  of  the  child,  is  caused  by  an  abnormal 
blood  supply,  a  form  of  congenital  nrevus  (Fig.  170). 


238 


ORTHOPEDIC  SUBGEBT 


Table  of  Weight,  Height,  and  Circumferejs^ce  of  the  Chest  in 
Childhood.     (Boas.) 


Pounds. 


Height. 


Chest. 


Kilos. 


Inches.       Cm. 


Inches. 


Cm. 


Birth    .    . 
6  months 

1  year    . 
18  months 

2  years    . 
3 


7.55 

3.43 

20.6 

52.5 

13.4 

7.16 

3.26 

20.5 

52.2 

13,0 

16.0 

7.26 

25.4 

64.8 

16.5 

15.5 

7.03 

25.0 

64.6 

16.1 

20.5 

9.29 

29.0 

73.8 

18.0 

19.8 

8.84 

28.7 

73.2 

17.4 

22.8 

10.35 

30.0 

76.3 

18.5 

22.0 

9.98 

29.7 

75.6 

18.0 

'        26.5 

12.02 

32.5 

82.8 

19.0 

1        25.5 

11.56 

32.5 

82.8 

18.5 

31.2 

14.14 

35.0 

89.1 

20.1 

30.0 

13.60 

35.0 

89.1 

19.8 

35.0 

15.87 

38.0 

96.7 

20.7 

34.0 

15.41 

38.0 

96.7 

20.5 

41.2 

18.71 

41.7 

106  8 

21.5 

i        39.8 

18.06 

414 

105.3 

21.0 

i        45.1 

20.48 

•44.1 

112.0 

23.2 

48.8 

19.87 

43.6 

110.9 

22.8 

49.5 

22.44 

46,2 

117.4 

23.7 

48.0 

21.78 

45.9 

116.7 

23.3 

54.5 

24.70 

48.2 

122.3 

24.4 

52.9 

24.01 

48.0 

122.1 

23.S 

60.0 

26.58 

50.1 

327.2 

25.1 

67.5 

26.10 

49.6 

126.0 

24.5 

66.6 

30.22 

52.2 

132.6 

25.8 

64.1 

29.07 

51.8 

131.5 

24.7 

72.4 

32.83 

54.0 

137.2 

26.4 

70.3 

31.87 

53.8 

136.6 

25.8 

79.8 

36.21 

55.8 

141.7 

27.0 

!        81.4 

36.90 

57.1 

14n.2 

26.8 

88.3 

40.04 

58.2 

147.7 

27.7 

91.2 

41.36 

58.7 

149.2 

28.0 

1         99.3 

45.03 

61.0 

155.1 

28.8 

]0(l.3 

45.50 

60.3 

153  2 

29.2 

110.08 

50.26 

63.0 

159.9 

30.U 

108.04 

49.17 

61.4 

155.9 

30.3 

34.2 
33.2 
42.0 
41.0 
45.9 
44  4 
47.1 
45.9 
48.4 
47.0 
51.1 
50.5 
52.8 
52.2 
54.8 
53.5 
59.1 
58.3 
60.6 
59  5 
62.2 
60.8 
63.9 
62.5 
65.6 
63.0 
67.2 
65.8 
68.8 
68.3 
70.6 
71.3 
73.3 
74.1 
76.6 
79.8 


The  Functional  Pathogenesis  of   Deformity. 

Wolff's  Law. — "Every  change  in  the  form  and  function  of 
the  bones  or  of  their  function  alone  is  followed  by  certain  definite 
changes  in  their  internal  architecture,  and  equally  definite  second- 
ary alternations  of  their  external  conformation,  in  accordance  with 
mathematical  laws." 

Mention  has  been  made,  and  will  be  made  again  from  time  to 
time,  of  the  adaptation  of  members  or  parts  to  abnormal  condi- 
tions, and  of  the  transformation  of  deformed  parts  to  the  normal 
when  the  improper  relations  of  weight  and  strain  have  been 
removed.  This  theory  or  law  of  functional  adaptation  has  been 
established  by  Professor  Julius  Wolff,  of  Berlin,  who  has  shown 
its  application  to  the  bones,  the  most  unyielding  structures  of  the 
body.  He  first  called  attention  to  the  fact  that  the  shape  of  a 
bone  Ls  the  effect  of  function.  It  is  the  effect  of  function  in  that 
if  the  work  required  of  it  had  been  different  its  shape  would  have 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY    239 

been  different.  This  function  has  shaped  not  only  the  external 
contour  but  the  internal  structure  as  well.  If  a  bone  is  broken, 
for  example,  the  neck  of  the  femur,  and  deformity  results,  the 
internal  architecture  is  no  longer  suitable  for  the  new  conditions 
of  weight  and  strain,  and  immediately  a  rearrangement  begias, 
which  finally  transforms  the  internal  structure,  not  only  in  the 
neighborhood  of  the  injury,  but  in  the  extremity  of  the  bone  also, 
to  adapt  the  deformed  part  as  well  as  may  be  to  the  work  that  is 
now  demanded  of  it. 

Fig.  171 


Dislocated  femur,  showing  the  atrophy  and  rearrangement  of  the  internal  structure 
as  compared  with  the  normal  (Fig.  172).     (Freiberg.) 

The  normal  bone  is  braced  most  thoroughly,  and  is  most  re- 
sistant at  the  points  where  most  work  is  required  of  it.  If  the 
weight  and  strain  are  for  any  reason  transferred  to  another  part, 
its  structure  becomes  hypertrophied  there,  and  correspondingly 
weakened  at  the  point  from  which  the  strain  has  been  removed. 
With  this  change  in  the  internal  structure  a  change  in  the  external 
contour  keeps  pace.  For,  according  to  this  theory,  "the  external 
contour  represents  mathematically  simply  the  last  curve  uniting  the 
ends  of  the  various  trajectories  which  make  up  the  internal  structure." 


240 


OE THOPEDIC  S UB GEB Y 


For  the  further  exposition  of  this  theory  I  quote  from  Frei- 
berg's^ re%-iew  and  abstract  of  Wolff's"  final  article. 

"In  showing  that  improper  static  demands  made  upon  an 
extremity  resulted  in  the  formation  of  new  masses  of  bone  upon 
the  surface  of  the  bone  of  this  extremity,  or. that  they  produce 
the  disappearance  (atrophy)  of  bone  masses  accordmg  to  the  nature 
and  degree  of  these  disturbances  in  static  requirements,  it  has  at 


Fig.  172 


Normal  femur  from  same  subject.      (Freiberg.) 

once  been  shown  in  what  manner  deformities  have  their  origin. 
Yov  these  transformations  on  the  surface  of  bone  are  nothing 
other  than  'deformities'  in  the  wider  or  narrower  sense  of  the 
term. 

"Taking  genu  valgum  or  hal^tual  scoliosis  as  an  example,  the 
developm(int  of  a  deformity  in  the  narrow  sense  is  thus  explained. 
In  the  beginning  of  either  of  these  conditions  the  shape  of  the 

'  Annals  of  Surgery,  July,  1897;  and  American  Journal  of  the  Medical  Sciences,  December, 
1902. 

''  iJie  Lehre  von  der  functionellen  Patliogene.se  der  Deformitiiten,  Archiv  f.  klinische 
Cbirurgie,  iid.  liii.,  H.  4. 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY    241 

bones  is  perfectly  normal.  As  the  result  of  excessive  fatigue  in 
their  too  weak  muscles  the  patients  are  frequently  assuming  a 
faulty  position  of  limb  or  body;  they  seek  to  control  excessive 
excursions  of  their  joints  by  the  interference  of  the  articular 
structures  themselves  instead  of  by  muscular  activity.  The 
result  is  a  continual  alteration  in  the  static  requirements  made 
upon  the  bones  and  the  internal  architecture;  internal  and  ex- 
ternal configuration  of  the  bones  accommodate  themselves  to  the 
new  conditions.  vSince,  a:ccording  to  this  reasoning,  deformities 
are  nothing  less  than  the  result  of  these  transformations  which 
the  external  form  of  bones  or  joints  undergo  in  accommo- 
dating itself  to   faulty  demands   made   upon  them,  it  must  be 

Fig.  173 


Section  of  femoral  head  of  a  paralytic  idiot,  aged  thirty-five  years,  showing  the  extreme 
atrophy  caused  by  disuse.     (R.  T.  Taylor.) 

self-evident  that  these  deformities  are  to  be  considered  patho- 
logical only  in  the  sense  that  hypertrophy  of  the  cardiac  muscle 
in  valvular  insufficiency  is  pathological.  That  which  is  really 
pathological  is  only  the  altered  static  requirements,  the  abnormal 
mechanical  function.  Far  from  being  pathological  the  deformity 
is  the  only  suitable  or  even  possible  form  by  means  of  which 
bone  or  joint  can  withstand  the  altered  forces  bearing  upon  it;  it 
is  nature's  way  of  securing  the  greatest  possible  service  and  strength, 
under  the  new  conditions,  with  the  use  of  the  least  possible  amount 
of  material. 

"  The  pathogenesis  of  deformities  is,  therefore,  functional.  Genu 
valgum,  for  instance,  represents  only  the  functional  accommo- 
dation  of  femur,  tibia,   and   knee-joint  to   the   improper  static 

16 


242  ORTHOPEDIC  HUBGERT 

demands  made  by  the  outward  deviation  of  the  leg.  Just  so  are 
the  shapes  of  the  bones  in  club-foot  the  expressions  of  similar 
functional  accommodation  to  an  inward  rotation  of  the  foot,  or 
even,  sometimes,  an  inward  turning  of  the  whole  lower  extremity. 
The  faulty  position  of  an  extremity  under  these  circumstances  is 
to  be  regarded  rather  as  a  cause  of  the  deformity  than  as  an  effect. 
This  faulty  position  must  always  occupy  a  place  intermediate 
between  the  remote  causes  of  deformity  (hereditary  predisposi- 
tion, habit,  muscular  Avealaiess,  external  conditions  causing 
pressure  or  narrowing  space  of  growth),  and  the  anatomical 
results  which  these  various  remote  causes  bring  about. 

"^^^len  the  altered  demands  upon  an  extremity  do  not  occur 
spontaneously,  as  in  the  above  instances,  but,  on  the  other  hand, 
result  from  a  primary  disturbance  in  the  shape  of  the  bones,  due 
to  trauma  or  bone  disease  with  consequent  softening  or  destruc- 
tion of  tissue,  there  is  added  to  this  a  secondary  change  in  the 
external  configuration  of  the  bones,  and  there  is  thus  caused  a 
'deformity  in  the  broad  sense  of  the  word.'  The  difference 
between  the  two  varieties  of  deformity,  therefore,  lies  only  in  the 
addition  of  a  second  etiological  factor  (the  trauma,  etc.)  to  the 
deformity  in  the  broad  sense.  Both  varieties  have  it  in  common 
that  the  shape  of  the  bones  and  johits  of  the  deformed  part  repre- 
sents nothing  else  than  the  expression  of  a  functional  accommo- 
dation to  the  faulty  static  demands  made  upon  it. 

"As  a  second  example  by  means  of  which  to  explain  the  cor- 
rectness of  the  doctrine  of  functional  pathogenesis  the  author  has 
selected  scoliosis.  In  the  first  chapter  the  author  showed  in 
detail  that  the  altered  conditions  in  the  length  and  height  of  the 
transverse  processes  of  scoliotic  vertebrae  as  well  as  corresponding 
conditions  in  the  ribs  of  the  scoliotic  thorax  are  so  evident  as  not 
possibly  to  escape  notice,  and  that  they  can  be  explained  in  no 
other  way  than  as  functional  accommodation  to  the  circumstances 
of  space,  changed  and  brought  about  by  the  continual,  faulty, 
and  cramped  position  of  the  thorax;  this  is  as  true  of  the  convex 
as  of  the  concave  side  of  the  vertebral  column,  to  which  the  trans- 
verse processes  and  ribs  in  question  belong.  It  must  be  manifest 
that  changed  relations  of  one  part  of  the  skeleton  to  any  other 
part  of  the  skeleton  (as  far  as  space  conditions  are  concerned) 
necessarily  bring  about  changes  in  the  mechanical  demands  made 
upon  this  part,  and,  therefore,  changes  in  the  directions  and  values 
of  the  pressure,  tension,  and  shearing  strains  of  each  and  every 
point  in  tliis  part  of  the  skeleton.     The  conclusion  thus  drawn, 


THE  FUNCTIONAL  PATHOGENESIS  OF  DEFORMITY    243 

that  accommodation  to  space  means  the  same  as  accommodation 
to  function,  is  of  greatest  importance  to  the  general  doctrine  of 
functional   accommodation, 

"The  origin  of  the  wedge-shape  of  the  scoHotic  vertebra  now 
comes  under  discussion.  It  is  assumed  by  the  majority  of  writers 
that  an  abnormal  softness  of  the  bones  is  present  in  scoliosis  by 
means  of  which  a  faulty  position  can  model  the  bodies  of  the 
vertebrae  as  it  does  in  the  case  of  rhachitic  disease  of  the  bone,  or 
as  is  really  the  case  with  the  intervertebral  disks  in  cases  of  'habit- 
ual scoliosis.'  While  unsupported  by  any  pathologico-anatomical 
investigations,  it  is  allowed  possible,  or  even  probable,  that  such 
softness  of  the  bones  plays  a  role  in  many  cases  of  scoliosis.  It 
is  certain,  however,  that  this  is  by  no  means  always  the  case; 
as  evidenced  by  the  development  of  scoliosis  after  empyema  in 
adults,  and  the  great  exaggeration  in  adult  life  of  very  slight 
scolioses  originating  during  youth.  It  is  concluded,  on  the  con- 
trary, that  the  vertebra  may  acquire  its  scoliotic  wedge-shape 
entirely  independent  of  the  pressure  of  the  superincumbent  weight. 
Furthermore,  in  the  absence  of  any  abnormal  softness  of  the  bones, 
the  body  of  a  vertebra  may  lose  height  on  the  concave  side  and 
gain  the  same  on  the  convex  side  through  the  'tropic  stimulus 
of  function'  purely;  being  simply  an  accommodation  to  the  dimin- 
ished space  on  the  concave  side  and  increased  room  at  the  con- 
vexity and  the  change  of  mechanical  conditions  consequent 
thereupon. 

"This  simple  and  natural  conception  of  the  circumstances  con- 
cerning the  scoliotic  wedge  must  obtain  credence,  especially  since 
the  old  view,  corresponding  to  the  'pressure  theory,'  ha,s  been 
long  ago  disproved  by  Hoffa  and  Nicoladoni — namely,  that  the 
concave  side  of  the  wedge  is  the  seat  of  atrophy,  and  that  this 
atrophy  accounts  for  the  loss  in  height  of  the  vertebral  body  on 
this  side." 

The  importance  of  Wolff's  theory,  which  shows  how  deformity 
may  be  acquired  and  how  it  may  be  avoided,  is  very  evident. 
It  is  of  equal  hnportance  in  indicating  the  principles  of  treatment. 
For  example,  from  the  anatomical  description  of  a  club  foot  tiie 
distortion  might  appear  to  be  irremediable,  but  on  this  theory 
one  feels  assured  that  if  the  foot  can  be  fixed  for  a  sufficient  time 
in  the  overcorrected  position,  the  influence  of  the  new  static  con- 
ditions will  immediately  induce  a  transformation,  not  only  in  soft 
parts,  but  in  the  bones  as  well,  that  will  finally  effect  a  complete 
and  absolute  cure.     So,  also,  the  correction  of  a  distorted  bone 


244  ORTHOPEDIC  SUROEBY 

by  operative  means  is  at  best  but  imperfect;  if,  however,  the 
static  conditions  have  been  changed,  nature  will  in  time  recon- 
struct the  entire  bone  so  perfectly  that  in  a  few  years  practically 
no  trace  of  the  former  distortion,  either  in  contour  or  internal 
structure,  will  be  e^^dent.  Scoliosis  might  be  cured  as  perfectly 
as  the  club  foot  or  the  bow-leg,  were  it  possible  to  restore  as  easily 
the  normal  conditions  of  weight  and  strain. 

Atrophy  of  Bone. 

The  writings  of  Wolff  have  emphasized  the  fact  that  bone  is  a 
living  tissue  very  readily  affected  by  changing  conditions,  and  that 
atrophy  or  hypertrophy  of  bone  may  be  local  or  general,  accord- 
ing to  the  change  in  functional  use  of  the  affected  part. 

Since  the  Roentgen  ray  has  come  into  general  use  particular 
attention  has  been  called  to  the  atrophy  of  the  internal  structure 
of  bone  that  follows  lessened  use  or  disuse,  or  from  what  is  called 
trophic  disturbance  of  nutrition  from  any  cause.  For  example, 
after  fracture  or  joint  disease,  or  nervous  affections,  or  even 
slight  injuries  of  the  nature  of  sprains,  eccentric  atrophy  is  ap- 
parent— that  is,  weakening  of  the  lamellae  of  the  spongy  por- 
tion and  decrease  in  thickness  of  the  compact  substance  of  the 
bone. 

This  atrophy  is  not  only  rapid,  but  it  may  be  widespread,  as 
proved  by  the  investigations  of  Sudeck,^  who  could  distinguish 
atrophy  of  the  bones  of  the  foot  within  six  weeks  after  fracture  of 
the  leg.  Atrophy  of  bone  is  especially  rapid  as  a  result  of  acute 
afFections  of  the  joints,  corresponding  in  this  to  the  atrophy  of 
the  muscles  under  similar  conditions.  In  the  x-ray  negative 
such  atrophy  is  indicated  by  a  loss  of  clearnsss  of  outline  which 
is  replaced  by  a  peculiar  blur,  resembling  closely  the  infiltration 
due  to  disease. 

Weigel  has  called  attention  to  cases  in  which  general  trophic 
disturbance  of  an  entire  extremity  was  induced  by  injury  of  a 
joint.  This  disturbance  was  indicated  by  congestion,  coldness  and 
persistent  weakness  of  the  extremity,  and  it  was  always  accom- 
panied by  marked  and  general  atrophy  of  the  bones.  These 
nutritive  changes  explain  the  delay  in  recovery  after  apparently 
slight  injury  or  disease  of  a  joint  or  other  tissue.  The  treatment 
therefore,  should  be  stimulative,  and  functional  use  of  the  weak 
part  should  be  encouraged  as  soon  as  possible.^ 

1  Fortsc.  auf  ilem  Gebiets.  der  KdntKff'strahlen,  Bd.  iii.,  H.  6. 
*  Mally  et  Itichon,  lievue  de  Chir.,  vols.  xxiv.  and  xxv. 


HYPERTROPHY  OF  BONE  245 

After  long-continued  disuse  the  bones  may  be  extremely  fragile. 
This  fact  must  be  borne  in  mind  when  one  attempts  to  correct 
deformity  caused  by  paralysis,  by  rheumatoid  arthritis,  and  the 
like. 

Hypertrophy  of  Bone. 

This  is  usually  due  to  disease.  It  may  be  general,  as  in  osteitis 
deformans.  It  may  affect  corresponding  bones,  as  in  syphilitic 
enlargement  of  the  tibiae,  or  it  may  be  limited  to  a  single  bone. 
Of  this  a  familiar  example  is  chronic  osteomyelitis,  which  may 
induce  thickening  and  elongation  of  the  affected  bone  sometimes 
to  the  extent  of  two  or  more  inches. 


CHAPTEE  V. 

TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS 

Etiology.— Three  factors  are  recognized  in  the  etiology  of 
tuberculous  disease:  the  infectious  element  (the  tubercle  bacillus), 
the  general  predisposition  of  the  patient,  and  the  local  condition 
that  favors  the  reception  and  the  growth  of  the  bacilli. 

Predisposition. — The  predisposition,  both  general  and  local, 
is  spoken  of  as  lessened  vital  resistance.  A  general  predisposi- 
tion to  disease  may  be  inherited  or  it  may  be  acquired.  Thus, 
a  history  of  tuberculosis  in  the  immediate  family  of  the  patient 
LS  supposed  to  imply  a  lessened  resistance  to  this  form  of  dis- 
ease. In  a  certain  proportion,  perhaps  25  per  cent.,  of  the 
cases  this  inherited  predisposition  is  very  direct  and  positive, 
but  in  the  larger  number  the  family  history  is  as  indefinite  as 
in  a  similar  class  of  patients  under  treatment  for  any  other  form 
of  ailment.  The  acquired  predisposition  is  of  more  direct 
importance,  since  it  would  include  the  lowering  of  the  vitality 
due  to  improper  food  and  improper  hygienic  surroundings  of 
every  variety,  together  with  the  greater  liability  to  depressing 
diseases  and  the  more  constant  exposure  to  tuberculous  infection 
that  such  conditions  imply.  Thus,  tuberculous  disease  of  the 
bones,  as  well  as  of  other  parts,  is  more  common  among  the  poor 
of  cities  than  among  the  more  favored  classes. 

Mode  of  Infection. — The  tubercle  bacilli  may  be  introduced  to 
the  body  by  inhalation  and  find  their  way  to  the  bronchial  glands, 
or  by  the  mouth  and  set  up  disease  in  the  mesenteric  glands, 
or,  after  infection  of  the  nasal  passages  oi"  neighboring  parts, 
secondary  disease  of  the  cervical  lymphatics  may  cause  the  so- 
called  scrofulous  glands  of  the  neck. 

Latent  Tuberculosis. — It  may  be  assumed  that  disease  of  the 
bronchial  and  mesenteric  glands  is  not  uncommon  in  individuals 
of  apparently  perfect  health,  since  it  is  often  discovered  at  au- 
topsi(;s  in  those  who  have  died  from  other  causes.  For  example 
in  2713  autopsies  on  children  who  died  of  acute  infectious  diseases 
reported  by  Ganghofner  tuberculous  tissues  were  found  in  562 
or  about  20  per  cent.  This  form  of  glandular  disease  is  called 
latent   tuberculosis,   and   it   usually   precedes   a   local   outbreak 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       247 

in  the  bone  or  elsewhere.  In  many  instances  the  disease 
may  remain  latent  and  finally  disappear,  or  it  may  persist, 
and  from  time  to  time  free  bacilli  or  bits  of  infected  tissue  may 
escape  into  the  blood  current;  by  it  they  are  deposited  in  other 
parts,  where,  under  favoring  conditions,  local  disease  may  be 
set  up.  Depression  of  the  vitality  from  any  cause  may  be  sup- 
posed to  favor  the  progress  of  the  glandular  disease,  which 
may  lead  to  a  dLssemination  of  the  infectious  elements,  and 
at  the  same  time  it  may  lessen  the  resistance  of  other  tissues 
that  may  be  exposed  to  the  infection.  This  accounts  for  the 
well-known  influence  of  certain  diseases,  such  as  measles  and 
whooping-cough,  not  only  in  predisposing  to  local  tuberculous 
disease,  but  in  favoring  its  progress  when  it  is  already  established. 
It  is  possible,  also,  that  the  bacilli  that  have  found  their  way 
into  the  blood  current  more  directly,  as,  for  example,  through 
wound  infection,  may  set  up  primary  disease  of  a  bone  or  joint. 
In  fact,  it  is  stated  by  Koenig^  that  in  fourteen  of  sixty-seven 
autopsies  on  subjects  who  had  suffered  from  tuberculous  dis- 
ease of  the  bones  and  joints,  no  other  foci  were  found  in  the 
body.  In  other  instances  the  source  of  infection  may  be  pre- 
existent  disease  of  the  lungs  or  of  other  internal  organs. 

In  769  autopsies  on  children  under  twelve  years  of  age,  at  the 
Hospital  for  Children,  Great  Ormond  Street,  London,  reported 
by  G.  F.  Still,^  269  presented  tuberculous  lesions.  Of  these,  117 
were  less  than  two  yeai-s  of  age. 

The  apparent  channels  of  infection,  as  evidenced  by  the  appear- 
ance of  the  glandular  lesions,  were  as  follows: 

Respiratory: 

Lungs 105 

Probably  lungs 33 

Ear • 9 

Probably  ear 6 

153  =  57  i>er  cent. 
Alimentary: 

Intestines 53 

Probably  intestines 10 

63=  23.4  per  rent. 
Other  cases: 

Bones  or  joints 5 

Fauces 2 

Uncertain 40 

53 

Northrup  and  Bovaird"^  have  made  similar  observations  at  the 
New  York  Foundling  Hospital: 

1  Deutsche  Chir.,  1900,  L.  28a,  S.  1.57.  -  Briti.^h  Afedical  Journal,  .\ufiust  19.  1S99. 

8  Northrup,   New  York  Med.   .lounuil,  February  21,   l.SiH.      Hovainl,   Ilii.l,.  .hily  1,  1899 


2i8  OB THOPEDIC  S UR  GEE  Y 

Infection  by  respiratory  tract 148 

Infection  by  mesenteric  lymph  nodes 3 

Indeterminate 48 

199 

In  sixteen  instances  the  process  was  confined  to  the  bronchial 
glands,  and  in  no  instance  were  these  glands  found  to  be  free  from 
disease. 

Bovaird^  has  collected  the  reported  autopsies  on  tuberculous 
children  with  reference  to  primary  intestinal  infection,  and  has 
called  attention  to  the  fact  that  the  English  observations  are  not 
in  accord  with  others: 

.    .      .  Primary  intestinal 

German 236  9  =    4  per  cent. 

French'     ......  128  0 

English 748  136  =  18 

American             .....  369  5  =    1         " 

1481  150 

Haushalter,^  in  78  autopsies  upon  children  dying  from  acute 
miliaiy  tuberculosis,  found  in  all  but  4  disease  of  the  tracheo- 
bronchial glands.  In  44  this  disease  was  the  most  ancient  focus 
in  the  body. 

Local  Predisposition. — The  local  conditions  that  favor  the 
growth  of  the  tubercle  bacilli  may  be  induced  by  injury.  Slight 
injury  sufficient  to  cause,  for  example,  a  hemorrhage  into  the 
substance  of  the  cancellous  tissue  induces  a  local  congestion  dur- 
ing the  process  of  repair  that  provides  the  proper  soil  for  the 
growth  of  the  bacilli  when  they  are  deposited  in  its  neighborhood. 
This  has  been  proved  experimentally  by  Krause,  and  it  is  sup- 
ported by  clinical  evidence.  The  great  preponderance  of  disease 
in  the  lower  over  that  of  the  upper  extremities  in  childhood  may 
be  cited  as  evidence  of  the  influence  of  injury  in  the  causation  of 
disease. 

In  513  of  3398  cases  of  tuberculosis  of  the  bones  and  joints 
reported  by  Hildebrand,^  Koenig,  Mikulicz,  and  Bruns  injury 
seemed  to  be  a  direct  predisposing  cause  of  the  local  disease 
(16.5  per  cent.).  A  much  higher  percentage  than  this  has  been 
assigned  by  certain  writers,  but  the  exact  relation  of  traumatism 
to  disease  can  only  be  conjectured.  For  example,  Voss'  in  577 
cases  treated  at  Rostock  found  injury  stat(;d  as  the  exciting  cause 
in  more  than  20  per  cent.  Yet  on  further  investigation  in  but  7 
per  cent,  could  its  influence  l)e  clearly  estal)lis]ie(l.''' 

'  Archives  of  Fediatricn,  TJecernbor,  1901.     -  Archiv.  de  M6(l.  den  ]')iifaiit.s,  March,  U)02. 
3  Deutsche  Chir.,   1902,  L.   13,  S.   168.  '  Zeit.  f.  (^hir.,  1904,  No.  16. 

'•  The  literature  of  the  nub.jcct  may  be  found  in  the  Archiv.  f.  Orthop.      M('chaiii('oMiora- 
pie  u.  Unfall  Chir.,  Hd.  iv.,  H.  4,  1906,  DeutMchlaiider. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       249 

The  primary  disease  is  almost  always  in  the  newly  formed 
bone  about  an  epiphyseal  cartilage.  This  tissue  is  vulnerable; 
it  is,  therefore,  more  exposed  to  direct  injury;  it  is  subjected, 
also,  to  the  strain  of  motion  at  the  neighboring  joint,  and  as  the 
circulation  is  here  more  active  the  bacilli  are  more  often  deposited 
in  this  situation. 

The  vulnerability  of  growing  bone  accounts  also  for  the  relative 
frequency  of  bone  disease  in  childhood,  as  compared  with  adult 
life.  Injury  not  only  causes  a  local  predisposition  to  disease,  but 
it  favors  its  progress  when  it  is  once  established. 

Distribution  of  the  Disease. — In  13,308  cases  of  tuberculous 
disease  of  the  bones  and  joints  treated  at  the  Hospital  for  Rup- 
tured and  Crippled  the  distribution  was,  in  order  of  frequency,  as 
follows : 

Vertebrte 5,662     =     42.5  per  cent. 

Hip-joint 4,048     =     30.5 

Other  joints 3,598     =     27.0 

13,308 

In  a  total  of  3561  cases  treated  at  the  Hospital  for  Ruptured 
and  Crippled  and  at  the  Vanderbilt  Clinic  during  a  period  of 
five  years  the  distribution  was  as  follows : 

Vertebrje 1432     =  40.2  per  cent. 

Hip-joint 1123     =  31.5 

Knee-joint 699     =  19.6 

Ankle-joint 196     =  5.5        " 

Elbow-joint 62  1 

Shoulder-joint 42  (.  =  3.1       " 

Wrist-joint 7  ( 


3561 

Trunk 1432     =     40.2  per  cent. 

Lower  extremities 2018     =     56.6 

Upper         "  Ill     =       3.1        " 

The  correspondence  between  these  two  tables  of  stiitistics  is 
striking,  and  the  number  of  cases  is  so  large  that  the  proportions 
may  be  accepted  as  approximately  correct  as  applied  to  the  dis- 
tribution of  the  disease  in  childhood. 

At  the  Boston  Children's  Hospital  in  a  period  of  twenty-five 
years,  1869-1893,  3820  cases  were  treated.^  The  distribution  was 
as  follows: 

Vertebra} 1964     =  51.4  per  cent. 

Hip 1402     -=-  36.7       " 

Ankle 300     -  7.8 

Knee 104     =  2.7 

Wri.st 20"! 

Shoulder 15  L^  1.3 

Elbow 15  J 

3820 

'    Report   of  the   Boston   Children's  Hospital. 


250  OR  TH  OPE  Die  SURGERY 

Trunk 1964     =     51.4  per  cent. 

Lower  extremities 1S06     =     47.2 

Upper  "  50     =       1.3 

Side  Affected.- — Disease  of  the  joints  is  slightly  more  comrQon 
on  the  right  than  on  the  left  side  of  the  body.  At  the  Hospital 
for  Ruptured  and  Crippled  the  proportions  in  the  cases  treated 
during  a  recent  period  of  ten  years  are  as  follows : 

Hip,  right 53    per  cent. 

Knee,  right 55         " 

Ankle,  right 50 

Shoulder,  right 64         " 

Elbow,  right 60 

It  has  been  stated  that  one  of  the  explanations  of  the  great 
preponderance  of  the  disease  of  the  lower  over  the  upper  extremity 
is  the  greater  liability  to  injury.  The  same  explanation  has  been 
advanced  to  account  for  the  greater  frequency  of  disease  on  the 
right  side,  which  is  more  marked  in  the  upper  than  in  the  lower 
extremity,  because  the  right  arm  is  more  liable  to  overwork  as 
well  as  to  injury. 

Sex. — Tuberculous  disease  of  the  joints  is  somewhat  more 
common  among  males  than  females. 

Of  3822  cases  of  Pott's  disease  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  2037,  or  53  per  cent.,  were  in  males. 

Of  3307  cases  of  disease  of  the  hip-joint  treated  at  the  same 
institution,  1731,  or  52.3  per  cent.,  were  in  males. 

Of  1218  cases  of  disease  of  knee-joint,  combined  statistics 
of  Koenig  and  Gibney,  703,  or  57.6  per  cent.,  were  in  males. 

Age. — In  5461  cases  of  tuberculous  disease  treated  at  the  Hos- 
pital for  Ruptured  and  Crippled,  about  seven-eighths  of  the 
patients  were  less  than  fourteen  years  of  age. 

(vertebrae,       87.7  per  cent, 
hip,  88.2        " 

other  joints,  71.7        " 

f  vertebraj,  7.7  per  cent. 

Between  14  and  21  years  of  age       ...       J  hip,  9.2 

I  other  joints,  10.7 

(vertebrae,  4.5  per  cent, 

hip,  2.5        " 

other  joints,  17.5^        " 

Of  1259  cases  of  Pott's  disease  treated  recently  at  the  same 
institution,  1075,  or  85  per  cent,  of  the  patients,  were  in  the  first 
decade;  50  per  cent,  were  three  to  five  years  of  age,  inclusive,  at 
the  inception  of  the  disease. 

In  1000  cases  of  disea.se  of  the  hip-joint  the  ages  of  the  patients 
correspond  closely  to  these;    87.2    per   cent,   were   in   the    first 

'  Knight.     Orthopedia. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       251 

decade  and  45.2  per  cent,  were  from  three  to  five  years  of  age, 
inclusive. 

In  1000  cases  of  disease  of  the  knee-joint,  75  per  cent,  were  in 
the  first  decade  and  40  per  cent,  were  from  three  to  five  years, 
inclusive. 

In  339  cases  of  the  ankle-joint,  70  per  cent,  were  in  the  first 
decade  and  but  35  per  cent,  were  included  within  the  three  years. 

The  distribution  of  the  disease  and  its  relative  frequency  at  the 
different  ages  is  shown  by  Alfer's  table  of  statistics  from  Tren- 
delenburg's clinic  at  Bonn.^ 


I  1                                               II 

0-5  &-10  lU-15  15-20  20-25125-30  30-35  35-40  40-45  45-50  50-55  55-60  60-65  65-70 

II  II 

Total 

Vertebrse 

89     59 

32       23 

9 

10 

3 

6         3 

1 

4 

0    !     0 

0 

239 

Hip 

58 

59 

43       46 

9 

11 

6 

0 

4 

1 

1 

3         0 

<J 

241 

Knee 

47 

52 

47       37 

20 

11 

23 

11 

11 

3 

2 

8     1     6 

3 

281 

Ankle 

5 

9 

10         5 

2 

1 

1 

3 

2 

0 

3 

0     1     2 

0 

43 

Shoulder 

0 

2 

2         6 

3 

5 

3 

1 

1 

2 

2 

1         0 

0 

28 

Elbow 

7 

14 

14       21 

12 

9 

6 

5 

9 

8 

5 

2         2 

0 

114 

Wrist 

1 

0 

0         1 

1 

5 

0 

0 

3 

1 

3 

2 

1         3 

0 

20 

Total 

207 

195 

148 

139 

60       47 

42 

29 

31 

18 

19 

15  [    13 

3 

966 

This  table  illustrates  the  well-known  fact  that  disease  of  the 
upper  extremity,  relatively  infrequent  at  all  ages,  is  proportion- 
ately far  more  common  in  adult  life  than  is  disease  of  the  lower 
extremity.  Of  the  joints  of  the  lower  extremity,  the  knee  and 
the  ankle  are  proportionately  more  often  diseased  in  later  life 
than  is  the  hip. 

Pathology. — Wlien  the  bacilli  are  deposited  in  a  part,  the  irri- 
tation of  their  toxins  causes  a  proliferation  of  the  fixed  cells 
which  lie  in  direct  contact  with  the  germs,  and  about  these  a  ring 
of  leukocytes  forms.  The  bacilli,  the  epithelioid  cells  including 
often  one  or  more  giant  cells,  together  with  the  surrounding  leu- 
kocytes, constitute  the  visible  tubercle  of  bone,  a  minute  grayish 
speck  in  the  cancellous  structure.  The  central  cells  about  the 
bacilli,  increasing  in  number,  deprived  of  nourishment  and  poisoned 
by  the  toxins,  die  and  are  disintegrated  to  granular  material, 
"caseate,"  and  the  tubercle  changes  to  a  yellow  color;  but  the 
bacilli,  multiplying  and  escaping,  form  new  tubercles  about  the 
original  focus,  which  coalesce  as  the  area  of  the  disease  enlarges. 
Meanwhile,  the  surrounding  tissue  becomes  congested,  as  the 
result  of  the  irritation,  and  the  fixed  cells  become  organized, 
or  partly  organized,  into  a  feeble,  ill-nourished  form  of  granula- 
tion tissup,  representing  the  effort  of  the  part  to  shut  out  and  to 


1   Beit,  zur  klin.  Chir.,  Kil.  viii.,  H.  2. 


252  OR  THOPEDIC  SURGERY 

expel  the  foreign  substances  formed  by  the  disease.  Or,  if  this 
local  resistance  is  effective,  the  cells  become  actually  organized  into 
firm  granulations  which  surround  and  destroy  the  germs,  and  then 
are  further  transformed  into  scar  tissue.  But  in  most  instances 
either  because  the  irritation  is  insufficient  or  because  of  the  defi- 
cient vitality  of  the  part,  the  granulations  are  feeble  and  unstable, 
and  they  in.  turn  becoming  infected  by  the  multiplying  bacilli 
serve  only  to  extend  the  area  of  the  disease.  This  granulation 
tissue,  before  and  after  the  stage  of  infection,  absorbs  and  destroys 
the  bone.  If  the  progress  of  the  disease  is  slow,  the  cancellous 
structure  is  completely  absorbed  or  is  represented  only  by  bone 
sand,  but  if  the  disease  infiltrates  the  bone  more  rapidly  it  may 
destroy  its  natality  while  its  structure  is  still  retained,  and  a 
sequestrum  is  formed.  Such  sequestra,  consisting  of  rounded, 
yellow,  crumbling  masses  of  cancellous  structure,  of  the  size  of 
a  pea  or  larger,  are  especially  common  in  epiphyseal  disease 
of  childhood.  In  rare  instances  wedge-shaped  sequestra  are 
found  with  the  base  at  the  periphery  of  the  epiphysis.  These 
are  supposed  to  be  caused  by  the  lodging  of  an  infected  embolus 
in  a  terminal  vessel,  thus  cutting  off  the  blood  supply. 

By  the  formation  of  new  tubercles  at  the  periphery,  and  by 
the  caseation  of  material  in  the  centre  of  the  diseased  area,  a 
cavity  in  the  bone  is  formed,  containing  the  debris  of  the  granu- 
lation tissue,  often  sequestra  of  larger  or  smaller  size,  and  a 
variable  amount  of  fluid,  made  up  of  serum  and  leukocytes,  that 
has  exuded  from  the  surrounding  granulations.  The  walls  of 
this  cavity  are  formed  by  tissues  in  which  the  disease  is  active; 
the  inner  layer  containing  the  tubercles  in  the  various  stages  of 
formation  and  decay,  the  outer,  composed  of  feeble,  ill-nourished, 
granulation  tissue  as  yet  not  infected,  and  beyond  this  the  softened 
and  infiltrated  bone.  If  the  disease  has  ceased  to  progress  in 
any  direction  the  granulations  contain  more  bloodvessels,  they 
are  of  firmer  consistency  and  more  perfectly  organized,  and  the 
substance  of  the  bone  is  harder,  showing  the  evidence  of  repair. 

One  termination  of  epiphyseal  disease  Ls  by  enclosure  of  the 
focus  by  resistant  granulations,  behind  which  the  bone  solidifies 
and  shuts  in  the  disease,  or,  in  favorable  cases  in  which  its  area 
is  small,  completely  absorbing  and  replacing  it  l)y  scar  tissue. 

Extra-articular  Disease. — As  a  rule,  tlu;  tendency  of  the  process 
is  to  expand  and  to  force  an  opening  through  the  cortex  of  the 
bone  to  the  exterior.  Fii  certain  cases  this  opening  ]nay  form 
outside  tlie  (•aj)siil('  of  the  joint,  and  tlirongli   it  tlu^  products  of 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS        253 

the  disease  may  be  discharged  into  the  overlying  tissues,  forming 
a  tuberculous  abscess.  Here,  the  same  process  of  infection  and 
extension  of  the  area  of  disease  continues,  but  more  rapidly  than 
when  it  was  confined  within  the  bone.  The  surfaces  of  the  muscles 
and  fascia  are  infected,  and  are  covered  with  an  abscess  mem- 
brane of  violet  or  grayish -yellow  color,  made  up  of  tuberculous 
tissue  and  masses  of  fibrin,  lying  upon  and  loosely  attached  to 
the  outer  inflammatory  or  healthy  granidations. 

The  tuberculous  fluid  is  usually  of  a  thin  consistency,  composed 
of  serous  exudation,  leukocytes,  fibrin,  masses  of  degenerated 
tissue,  and  fragments  of  bone  or  bone  sand.  It  is  commonly  of 
a  whitish  color,  occasionally  reddish  from  mixture  with  blood, 
and,  in  the  later  stages,  yellow  and  serous-like.  The  abscess 
enlarges  in  the  direction  of  least  resistance,  and  in  most  instances 
finally  perforates  the  skin  by  one  or  more  openings  through  which 
its  contents  are  discharged.  Or,  its  boundaries  may  cease  to 
extend,  its  contents  may  be  absorbed,  adhesions  may  form 
between  its  walls,  and  a  spontaneous  cure  is  effected.  Extra- 
articular disease,  without  ultimate  involvement  of  the  joint,  is 
unusual.  It  is  more  common  at  those  joints  like  the  knee,  elbow, 
and  ankle,  in  which  the  bones  are  superficial;  it  is  very  uncom- 
mon at  the  hip-joint,  and  it  is  practically  impossible  in  disease 
of  the  spine. 

Perforation  of  the  Joint. — Usually  the  tuberculous  process  within 
the  epiphysis,  enlarging  its  area,  comes  into  contact  with  cartilage, 
and,  perforating  this,  finds  its  way  into  the  joint.  While  the 
disease  is  still  confined  within  the  bone,  the  tissues  within  the 
joint  are  involved  in  a  sympathetic  irritation  or  inflammation. 
The  synovial  membrane  becomes  congested  and  hypertrophied ; 
the  synovial  fluid  is  increased  and  changed  in  quality;  fibrin 
forms  and  is  deposited  upon  the  cartilage  and  upon  the  linino- 
membrane  of  the  capsule.  It  Is  stated  by  Koenig  that  the  or- 
ganization of  these  fibrinous  deposits  upon  the  cartilage  plays 
an  important  part  in  its  destruction^^^ven  when  actual  tuberculous 
disease  is  absent.  As  a  result  dfthe  sympathetic  iuHammation 
within  the  joint,  adhesion,'^ may  form  which  may  limit  the  area  of 
the  tuberculous  disease  and  retard  its  progress  after  perforation  lias 
taken  place.  This  process  is  similar  to  the  inflammatory  chano-cs  in 
the  pleura  caused  by  underlying  tuberculous  disease  of  the  In  no-. 

When  the  disease  comes  in  contact  with  the  cartilage  it  disin- 
tegrates; the  tuberculous  granulations  breaking  thi-ough  and 
spreading  over  lis  surface  destroy  it  in  piecemeal,  or,  advancing 


254  OR TSOPEDIG  SURGERY 

beneath  it,  separate  it  from  the  bone  in  large,  necrotic  fragments. 
The  s}^lo^-ial  membrane  becomes  thickened  and  infikrated, 
numerous  tubercles  appear  upon  its  surface,  which  undergo  the 
secondary  changes  that  have  been  described,  and  the  joint  be- 
comes, practically  speaking,  an  abscess  cavity.  The  surfaces 
of  the  bones  are  disintegrated  by  the  disease,  and  the  destruction 
is  hastened  by  the  pressure  and  friction  due  to  muscular  spasm 
and  to  functional  use.  The  thickened  capsule,  distended  by  the 
fluid  and  solid  products  of  the  disease,  is  usually  perforated,  and 
a  secondary  abscess,  communicating  with  it,  is  formed  in  the  sur- 
rounding tissues.  As  results  of  the  disease,  secondary  changes 
appear  in  the  neighboring  parts.  The  irritation  of  the  periosteum 
if  the  disease  is  of  a  quiescent  type,  may  induce  the  formation  of 
irregular  layers  of  bone  or  osteophytes  about  the  joint.  A  new 
formation  of  connective  tissue  proceeding  from  the  layer  of  granu- 
lations that  surround  the  disease  may  extend  to  the  muscles  and 
tendon  sheaths,  binding  them  together,  and  causing  limitation  of 
motion.  The  newly  formed  connective  tissue  may  be  very  vas- 
cular and  irregular  in  formation,  and  intermixed  with  it  may  be 
masses  of  gelatinous  or  myxomatous  tissue.  This,  according  to 
Krause,  is  due  to  the  venous  stasis  and  oedematous  infiltration 
caused  by  the  pressure  of  the  capsular  contents  and  extracapsular 
proliferation  of  granulation  tissue.  These  changes  in  the  appear- 
ance and  in  the  consistency  of  the  tissues  about  the  joint  are  char- 
acteristic of  the  so-called  white  swelling. 

Tuberculous  disease  is  most  common  in  the  neighborhood  of 
the  epiphyseal  cartilage,  thus  involving  the  joints.  Occasionally, 
however,  it  may  appear  primarily  in  a  diaphyses.  A  familiar 
example  is  central  disease  of  the  phalanges — "spina  ventosa" — a 
slow  infiltrating  form  of  disease  accompanied  often  by  sinus 
formation.  Distortion  and  atrophy  follow.  In  this  form  of 
disease  the  infection  is  often  multiple. 

Other  Forms  of  Tuberculous  Disease  of  Joints.— All  of  the 
German  writers  describe  forms  of  primary  synovial  disease,  its 
frequency  varying  from  16  to  35  per  cent,  of  the  cases.  It  is 
more  common  in  adult  life  than  in  childhood,  and  at  the  knee 
than  at  other  joints.  Nichols,^  on  the  other  hand,  states  that  he 
has  examined  120  tuberculous  joints,  and  has  found  in  every 
instance  one  or  more  foci  in  the  bone  that  apparently  preceded 
the  disease  in  the  joint.  This  is  certainly  not  in  accord  with 
clinical  experience,  for  one  must  recognize  a  form  of  disease  in 

'  Transactions  American  Orthopedic  Association,  vol,  xi. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       255 

which  the  symptoms  differ  from  the  ordinary  osteal  type.  Ii 
begins  as  a  chronic  synovitis,  ahhough  the  tissues  are  more  thick- 
ened and  infiltrated  than  in  simple  synovitis,  and  the  muscular 
atrophy  is  more  marked.  Reflex  spasm  and  limitation  of  motion 
are  slight,  and  the  symptoms  are  rather  discomfort  and  fatigue 
after  exertion  than  actual  pain.  After  many  months  or  years, 
when  it  may  be  assumed  the  bones  are  involved,  the  characteristic 
symptonis  of  tuberculous  disease  appear.  In  one  form  of  syno- 
vial disease  the  amount  of  effused  fluid  is  large,  and  it  is  clear 
and  serous-like  in  character — hydrops  tuberculosus;  but  ustially 
it  is  cloudy,  and  it  may  be  purulent  in  character. 

As  has  been  stated,  Koenig  lays  stress  upon  the  important  part 
played  by  fibrin  in  the  changes  that  take  place  within  a  joint. 
Fibrin  deposited  from  the  effused  fluid  forms  in  successive  layers 
upon  the  cartilage.  Into  this  fibrin  vessels  grow  from  the  hy- 
pertrophied  and  infected  synovial  membrane,  destroying  the 
cartilage  together  with  the  underlying  bone.  If  the  synovial 
disease  is  primary  the  bone  is  destroyed  superficially,  but  if  it  is 
secondary  to  synovitis  disease  within  the  epiphysis  it  is  usually 
more  extensive.  Synovial  tuberculosis  is  essentially  a  chronic 
affection  and  is  often  mistaken  for  simple  or  so-called  rheumatic 
synovitis. 

Arborescent  Synovial  Tuberculosis. — ^In  this  form  the  interior  of 
the  joint  is  covered  with  villous  proliferations  of  the  synovial 
membrane.  It  is  not  a  distinct  disease,  but  is  an  irritative  hyper- 
trophy that  is  present  in  syphilitic  and  rheumatic  as  well  as  in 
tuberculous  joints.  Its  especial  interest  lies  in  the  fact  that  the 
hypertrophied  synovial  growtlis  may  cause  mechanical  interfer- 
ence with  the  function  of  the  joint. 

Lipoma  Arborescens. — Arborescent  villous  proliferations  are 
formed  of  adipose  and  fibrous  tissue  covered  with  a  layer  of  round 
cells.  The  hypertrophied  masses  which  project  into  the  joint  arc 
often  of  large  size,  attached  to  the  synovial  membrane  by  a 
smaller  pedicle.  They  are  single  or  multiple,  and  vary  in  color 
from  yellow  to  deep  red.  They  may  be  of  a  soft  or  firm  consist- 
ency. In  this  form  of  disease, -as  in  that  described  in  the  pre- 
ceding section,  there  is  usually  pain,  limitation  of  motion;  often 
the  swollen  joint  is  irregular  in  outline;  the  hypertrophied  syno- 
vial prolongations  are  sometimes  apparent  on  palpation.^  The 
exact  diagnosis  is  usually  made  only  after  an  exploratory  incision, 
and  in  such  an  event  the  removal  of  the  larger  growths  would 
be  indicated.     The  outcome  depends,  of  course,  upon  the  cause, 


256 


0  R  THOPEDIC  S  UR  G  ER  Y 


the  hypertrophy  depending  usually  on  an  underlying  tuberculous, 
syphilitic,  or  so-called  rheumatoid  disease.  In  the  instances  in 
which  the  hypertrophied  tissue  is  in  itself  the  cause  of  the  dis- 
ability, cure  may  follow  its  removal. 

Rice  Bodies. — Rice  bodies  are  numerous  small,  grayish-white 
bodies  resembling  cucumber  seeds  that  are  found  in  certain  forms 
of  synovial  disease,  and  particularly  in  tuberculosis  of  tendon 
sheaths.  They  are  formed  of  fragments  detached  from  the  pro- 
liferating synovial  membrane  and  possibly  of  simple  fibrin,  which, 
under  the  influence  of  pressure  and  attrition  in  the  movements  of 
the  joint  or  of  the  tendon,  assume  the  characteristic  shape  and 
appearance.  These  bodies,  within  a  tendon  sheath  or  joint,  cause 
a  peculiar  creaking,  perceptible  to  the  touch  when  the  part  is 
moved. 

Fig.  174 


Li|)oma  urborescens.     (Painter  ami  Erving.) 


Dry  Caries.  Caries  Sicca. — In  this  form  of  disease,  which  is 
apparently  pri)narily  synovial,  there  Ls  but  little  formation  of 
Huid,  and  there  is  but  little  tendency  toward  cheesy  degeneration 
of  the  tuberculous  products.  The  infected  granulations  destroy 
the  bone  without  forming  secjuestra,  and  usually  without  sup- 
puration, '^riiis  form  more  often  occurs  at  the  shoulder-joint, 
and  it  is  characterized  by  marked  limitation  of  motion,  extreme 
atrophy  of  the  surrounding  parts,  and  sometimes  by  forward 
displacement  of  the  partly  destroyed  head  of  the  humerus  that 
may  be  mistaken  for  a  primary  dislocation. 

•  Painter  and  l>vin(?,  IJoHton  Med.  ami  Siu'k.  Journal,  March  19,  1903. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS        257 

Septic  Infection. — When  a  tuberculous  abscess  has  opened  spon- 
taneously, or  when  it  has  been  incised,  infection  with  pyogenic 
germs  is  common,  and  it  occasionally  occurs  before  a  communi- 
cation with  the  exterior  has  been  established. 

After  such  infection  the  surrounding  tissues  become  infiltrated, 
reddened,  and  sensitive  to  pressure.  The  discharge  is  greatly  in- 
creased in  quantity  and  changed  in  quality.  The  local  pain  and 
discomfort  are  aggravated;  if  the  joint  is  involved  the  destruction 
of  the  bone  goes  on  with  increased  rapidity,  and  the  constitutional 
effects  of  pyogenic  infection  appear.  If  the  area  of  the  abscess  is 
small  and  if  the  drainage  is  efficient,  this  accident  is  of  slight  impor- 
tance, and  it  may  even  exercise  a  beneficial  effect  in  stimulating 
the  circulation  and  dissolving  the  effused  material  about  a  joint. 
But  if  the  abscess  has  burrowed  widely  into  surrounding  tissues 
and  if  it  communicates  with  an  important  joint  it  is  a  dangerous 
•complication;  in  fact,  the  greatest  direct  danger  of  tuberculous 
joint  disease.  Persistent  suppuration  exhausts  the  patient,  anrl 
by  lessening  the  vital  resistance  it  favors  the  local  advance  of  the 
tuberculous  disease  and  its  general  dissemination.  It  is  in  this 
class  of  cases  that  amyloid  degeneration  of  the  internal  organs  is 
common,  induced  not  by  tuberculous  disease,  but  by  the  secondary 
infection  and  its  consequences. 

Repair. — Repair  in  tuberculous  disease  may  be  accomplished 
by  the  absorption,  ejection,  or  enclosure  of  the  disease.  The 
process  of  repair  usually  accompanies  the  advance  of  the  destruc- 
tive process,  and  examples  of  the  three  methods  of  cure  may  be 
found  in  a  single  joint. 

The  curative  agent  is  the  granulation  tissue  which  forms  about 
the  area  of  disease,  and  which,  finally  becoming  sufficiently  organ- 
ized to  resist  the  infection  of  the  bacilli,  solidifies  into  fibrous 
tissue.  In  those  cases  in  which  the  disease  is  not  absorbed  or 
completely  thrown  off  in  the  abscess  formation,  but  is  enclosed,  it 
becomes  quiescent.  In  such  cases  traumatism,  when,  for  example, 
the  surrounding  adhesions  are  broken  down  in  the  attempt  to 
rectify  deformity  or  to  overcome  anchylosis,  may  cause  local 
recurrence  of  the  disease. 

Prognosis. — The  prognosis  will  be  considered  more  particularly 
in  the  sections  on  disease  of  special  parts.  The  danger  to  life  is 
direct  and  indirect,  and  this  varies  greatly  with  the  part  that  is 
affected  and  with  the  age  of  the  patient. 

In  disease  of  the  spine  the  direct  danger  to  life  is  greater  than 
in  joint  disease,  because  of  its  situation,  since  it  mav  involve  the 

17 


258  .  ORTHOPEDIC  SURGERY 

spinal  cord  or  extend  to  the  important  organs  in  the  neighborhood. 
Abscess  may  in  rare  instances,  merely  by  its  size  and  situation, 
endanger  life,  and  when  infected  it  is  far  more  dangerous  because 
of  the  difficulty  in  providing  efficient  drainage.  The  influence  of 
deformity  and  its  effect  in  compressing  the  internal  organs  and  thus 
interfering:  "^'ith  the  vital  functions  is  another  more  remote  element 
of  danger  in  disease  in  this  situation. 

The  danger  to  life  from  disease  of  the  joints  is  in  proportion  to 
importance.  In  rare  instances  it  may  extend  from  the  epiphysis 
to  the  shaft  of  a  bone  and  set  up  an  extensive  osteomyelitis;  or 
the  patient  may  be  weakened  by  the  suffering  caused  by  active 
disease,  but,  as  has  been  stated,  the  most  direct  and  constant 
danger  is  from  prolonged  suppuration  that  follows  septic  infection. 
Danger  from  this  source  is  much  greater  at  the  hip-joint  than  at 
the  ankle  or  elbow,  for  example,  because  of  the  greater  difficulty 
in  preventing  the  burrowing  of  pus  when  infection  has  occurred.  ■ 

The  indirect  danger  of  tuberculous  disease  is  its  dissemination 
to  more  important  organs.  But  it  by  no  means  follows  that  the 
disease  of  the  joint  is  the  source  of  the  general  infection.  For,  as 
has  been  stated,  it  may  be  inferred  that  nearly  every  patient  with 
joint  disease  has  also  disease  of  the  lymphatic  glands,  and  in  a 
certain  proportion  of  the  cases  there  may  be  active  disease  of  other 
important  organs  as  well.  Tuberculosis  of  the  lungs,  for  example, 
is  often  present  in  the  adult  before  the  local  outbreak  in  the  joint 
appears,  and  it  is  in  great  degree  because  of  this  liability  to  disease 
of  the  lungs  that  the  prognosis  of  joint  disease  becomes  progres- 
sively worse  with  the  age  of  the  patient. 

This  point  is  illustrated  by  the  statistics  of  Koenig  and  Bruns 
on  the  final  results  of  disease  of  the  knee-  and  hip-joints,  to  which 
attention  will  be  called  again  in  the  special  sections.  In  Koenig's 
cases  of  disease  of  the  knee-joint  the  influence  of  age  upon  the 
death-rate  is  illustrated   by  the  following  table: 

Less  than  15  years  of  age 20  per  cent. 

From  16  to  30  years 24 

"      30  to  40     " 44 

More  than  40       " 60 

In  Bruns'  statistics  the  death-rate  was  of  patients  in  the  first 
decade,  36  per  cent.;  in  the  second  decade,  44  per  cent.;  older 
than   this,   72   per  cent. 

The  cure  of  latent  tuberculosis  in  the  lymph  nodes  as  well  as 
of  active  disease  of  the  lungs  or  bones  depends  upon  the  vital 
resistance  of  the  patient.  This  vital  resistance  is  lessened  by 
pain,  by  confinenient  and  lack  of  exercise.     It  is  directly  impaired 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       259 

by  the  exhausting  suppuration  and  by  the  poisoning  of  the  toxins 
incidental  to  septic  infection.  Under  these  conditions  the  local 
disease  advances  and  a  general  dissemination  Is  more  probable. 
This  accounts  for  the  fact  that  death  from  general  tuberculous 
infection  is  far  more  common  in  this  class  than  when  suppura- 
tion has  been  slight  or  absent.  This  point  Ls  again  illustrated 
by  the  statistics  referred  to.  The  death-rate  in  the  cases  of  dis- 
ease at  the  knee  without  abscess  was  25  per  cent.,  with  al)scess 
46  per  cent.  Death-rate  in  cases  of  disease  at  the  hip  with  ab- 
scess 52  per  cent.,  without  abscess  23  per  cent. 

It  is  probable  that  tuberculosis  may  be  disseminated  by  opera- 
tion upon  tuberculous  joints,  although  the  evidence  upon  this 
point  is  vague  and  conflicting.  Gibney,  contrasting  two  ecjual 
periods  of  thirteen  years  of  service  at  the  Hospital  for  Ruptured 
and  Crippled,  in  the  first  of  which  no  operations  were  performed 
on  tuberculous  subjects,  states  that  in  his  opinion  the  deaths  from 
this  source  have  been  proportionately  no  greater  during  the  period 
of  active  surgical  intervention  than  before.  And  an  investiga- 
tion of  the  causes  of  deaths  among  the  patients  treated  at  the 
New  York  Orthopedic  Dispensary  and  Hospital  during  a  period 
of  twenty  years  showed  that  at  least  25  per  cent,  of  these  were 
due  to  tuberculous  meningitis.^  During  this  period  there  had 
been,  practically  speaking,  no  operative  intervention,  yet  the 
proportion  of  deaths  from  this  cause  Is  certainly  as  great  as  in 
any  statistics  that  have  been  reported.  It  would  appear,  then, 
that  the  danger  of  dissemination  is  not  sufficient  to  deter  one 
from  performing  any  operation  that  seems  to  be  indicated  by  the 
character  of  the  local  disease  or  by  the  general  condition  of  the 
patient. 

Diagnosis. — Diagnosis  is  considered  at  length  in  the  sections 
on  diseases  of  the  special  joints.  The  tuberculin  test,  although  of 
some  importance  from  the  negative  standpoint,  is  of  no  partic- 
ular value  as  establishing  a  diagnosis  of  joint  disease,  for  the 
reason  that  tuberculous  disease  of  the  lymph  glands  is  so  com- 
mon even  among  those  whose  joints  are  free  from  disease.  For 
the  same  reason  it  is  valueless  as  a  test  of  practical  cure.  This  is 
illustrated  by  the  investigations  of  Frazier  and  Biggs^  of  patients 
clinically  cured  of  local  tuberculosis,  some  by  operative  means. 
In  78  per  cent,  of  these  a  positive  reaction  to  tuberculin  wa-s  ob- 
tained.    In  some  instances  however,  a  local  reaction  may  indicate 

'   Personal   coiniminication    from    Dr.    Diiviil    Bovaird. 
-  University   Medical   Magazine,   February,    1901. 


260  OB THOPEDIC  SUBGEBY 

foci  of  disease  whose  presence  would  not  otherwise  have  been 
suspected. 

Tinker,  who  has  reported  a  series  of  four  hundred  tests  from 
Johns  Hopkins  Hospital,  states  that  healthy  individuals  react  if  the 
dose  is  sufficiently  large.  One,  therefore,  begins  with  small  injec- 
tions, from  1  to  3  milligrams  of  Koch's  old  tuberculin.  This  may 
be  increased  to  9  milligrams,  a  reaction  to  less  than  this  amount 
being  practically  positive  if  the  temperature  of  the  patient  taken 
at  intervals  of  two  hours  for  at  least  eighteen  hours  has  been 
normal.     The  reaction  appears  in  from  six  to  eight  hours. 

The  x-rmj  is  often  of  value  in  demonstrating  the  effects 
of  disease,  and  in  certain  instances  it  may  indicate  its  exact 
locality  and  extent.  As  a  means  of  early  diagnosis  of  joint  dis- 
ease in  young  subjects,  however,  it  is  of  little  importance  as 
compared  to  the  physical  signs,  because  of  the  non-development 
of  the  bony  structure  of  the  epiphysis,  which  alone  appears  in 
the  negative. 

Treatment. — From  what  has  been  stated  of  the  causes  of  dis- 
ease it  follows  that  the  general  treatment  should  include,  if  possible, 
a  change  in  the  hygienic  conditions,  relief  from  the  danger  of 
further  infection,  pure  air,  and  proper  food.  These  are  as  essen- 
tial in  the  treatment  of  tuberculosis  of  the  bones  as  of  other  parts. 

The  importance  of  the  constitutional  treatment  of  tuberculous 
disease,  more  particularly  the  proper  environment  in  which  the 
greater  part  of  the  day  and  even  the  night  may  be  passed  in  the 
open  air,  can  hardly  be  exaggerated. 

As  far  as  the  cure  of  local  disease  is  concerned,  no  treatment 
can  be  as  effective  as  the  prompt  and  thorough  removal  of  the 
focus  of  disease,  while  it  is  yet  limited  in  extent,  and  before  the 
joint  has  become  involved.  This  is  practicable,  however,  in  but 
a  small  proportion  of  the  cases  in  childhood,  because  it  is  usually 
impossible  to  locate  the  disease  accurately  and  impossible  to 
remove  it  without  sacrificing  much  of  the  healthy  bone  upon 
which  the  future  usefulness  of  the  part  depends.  At  one  time 
early  operation,  even  complete  excision  of  the  joint,  was  justified 
on  the  plea  that  the  disease  might  thus  be  eradicated.  But  now 
that  it  Is  known  that  in  nearly  all  cases  other  tuberculous  foci 
exist  in  the  body,  and  as  the  functional  results  after  these  early 
operations  are  far  inferior  to  those  attained  under  conservative 
treatment,  early  excisions  are  limited  to  the  adolescent  or  adult 
cases.  For  in  this  class  growth  has  been  attained  and  the  econ- 
omic ccnditions  require  that  the  period  of  disability  should  be  as 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       261 

short  as  possible.  In  this  class,  also,  early  exploratory  opera- 
tions are  often  indicated,  sometimes  for  the  purpose  of  establish- 
ing the  diagnosis,  and  if  the  disease  is  of  the  synovial  type  the 
removal  of  projecting  folds  of  hypertrophied  tissue  and  the  direct 
application  of  irritants,  for  example,  of  pure  carbolic  acid,  may 
be  of  service.  Brace  treatment  is  conducted  with  the  aim  of 
relieving  the  part  of  function — that  is  to  say,  from  strain  and 
injury.  Functional  use  of  a  diseased  joint  delays  natural  repair, 
since  it  causes  pain  and  thus  reduces  the  reparative  force,  while  it 
stimulates  the  disease  and  increases  its  destructive  action.  The 
details  of  treatment  will  be  described  in  the  consideration  of  disease 
of  special  joints, 

Treatin'»*nt  by  Drugs. — The  administration  of  drugs  occupies  a 
very  subordinate  place  in  treatment,  since  it  is  not  believed  that 
any  drug  exercises  a  direct  action  upon  the  local  disease  in  the 
bone. 

Cod-liver  oil,  the  hypophosphites,  the  various  preparations  of 
iron  or  other  tonics  may  be  given  at  certain  times  with  benefit, 
but  the  continuous  administration  of  medicine  during  the  years 
that  are  required  to  complete  a  cure  is,  of  course,  out  of  the 
question. 

Local  Applications.  Iodoform. — Iodoform  is  supposed  to  exer- 
cise a  direct  germicidal  action  and  also  to  stimulate  the  forma- 
tion of  the  granulations  that  cast  off  or  absorb  the  tuberculous 
products  and  then  become  transformed  into  fibrous  tissue.  At 
one  time  direct  injection  of  the  remedy  into  the  bones  was 
advocated,  but  this  has  now  been  abandoned,  and  its  use  is  prac- 
tically limited  to  the  treatment  of  tuberculous  abscesses  and 
certain  forms  of  synovial  tuberculosis.  Iodoform  is  ordinarily 
employed  in  an  emulsion  with  glycerm  or  oil,  10  c.c.  of  10  per 
cent,  mixture  being  injected  at  intervals  of  two  or  more  weeks. 
Several  deaths  from  iodoform  poisoning  have  been  reported,  but 
injections  of  this  quantity  of  the  drug  are  apparently  free  from 
danger. 

Iodoform  Filling  for  Bone  Cavities. — V.  Mosetig-^Ioorhof ' 
uses  a  mass  made  up  of  finely  powdered  iodoform  60  parts, 
spermaceti  and  oil  of  sesamum  20  parts  each.  The  mixture, 
which  becomes  fluid  at  50°  C,  is  throughly  stirred  before  using. 
The  cavity  in  the  bone  having  been  made  thoroughly  dry  is  filled 
with  the  fluid,  which  solidifies  as  the  temperature  is  lowered.     The 

1  Deutsche  Zeitsc.  f.  Chir.,  vol.  Lsxi.,  No.  5. 


262  ORTHOPEDIC  SURGEBY 

wound  is  then  closed.  The  filhng  is  slowly  absorbed,  its  object 
being  to  preserve  the  contour  of  the  bone.  In  a  series  of  220 
cases  reported  by  this  author  no  local  disturbance  followed  the 
procedure. 

Carbolic  Acid. — Carbolic  acid  in  dilute  solutions  was  at  one 
time  injected  in  tuberculous  cavities,  but  its  use  has  been  gen- 
erally discontinued  because  of  the  danger  of  poisoning.  Recently 
Phelps  has  advocated  the  use  of  pure  carbolic  acid  in  the  treatment 
of  tuberculous  abscesses  and  sinuses.  This  is  injected  into  the 
fistulse  or  into  the  abscess  ca^dty,  which  has  been  opened,  and 
is  allowed  to  remain  for  about  a  minute,  when  it  is  neutralized 
by  copious  injections  of  alcohol,  after  which  the  part  is  thoroughly 
cleansed  by  salt  solution.  Carbolic  acid  doubtless  acts  as  a 
caustic,  destro}dng  the  infected  granulations  and  stimulating  the 
reparative  processes.  Other  remedies  of  this  class,  for  example 
tincture  of  iodine,  chloride  of  zinc,  actual  cautery  and  the  like, 
are  also  used,  and  in  certain  cases  with  benefit.  In  the  treatment 
of  tuberculous  ulcerations  ichthyol,  balsam  of  Peru,  and  iodoform 
are  among  the  drugs  employed.  Balsam  of  Peru  dissolved  in 
castor  oil  of  a  strength  of  about  10  per  cent.,  as  suggested  by 
Van  Arsdale,  is  a  very  satisfactory  application. 

X-ray  Treatment. — ^The  x-ray  as  a  local  treatment  appears  to 
act  as  a  stimulant  of  the  reparative  processes.  It  is  of  especial 
value  as  an  adjunct  in  the  cases  in  which  the  tissues  about  the 
joint  are  infiltrated  and  traversed  by  discharging  sinuses.  The 
exposure  of  the  diseased  tissues  to  the  direct  rays  of  the  sun  is 
certainly  a  harmless  treatment,  and  it  should  be  applied  if  occasion 
offers. 

ACTIVE    AND    PASSIVE    CONGESTION    IN    THE    TREATMENT 
OF  AFFECTIONS   OF   THE  JOINTS. 

Bier's  treatment  of  tuberculous  joint  disease  was  suggested  by 
the  observation  of  Rokitansky,  that  phthisis  was  uncommon  in  indi- 
viduals suft'ering  from  disease  of  the  heart  when  the  mechanical 
ol>struction  was  sufficient  to  cause  venous  congestion  of  the  lungs. 

Passive  or  venous  congestion  of  a  joint  is  attained  by  con- 
stricting the  limb  with  sev(!ral  circular  turns  of  a  rubber  bandage 
above  the  affected  joint  sufficiently  to  interfere  with  the  return  of 
the  venous  blood,  but  not  with  the  arterial  supply. 

The  congestion  is  localiz(;(l  by  bandaging  the  liml)  firmly  with 
flannel  or  other  soniewhat  elastic  material  up  to  the  lower  margin 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       203 

of  the  joint.  When  properly  appUed  the  joint  Ijecomes  swollen 
and  dark  red  in  color.  The  local  temperature  Ls  raised.  This 
is  what  Bier  calls  hot  congestion,  as  distinct  from  oedema  (cold 
congestion),  that  would  result  if  the  rubber  bandage  were  applied 
so  tight  as  to'  constrict  the  arteries.     Passive  congestion  should 


Fig.    175 


Fig.    176 


The  alcohol  lamp  and  chimney.     Used 
for  active  congestion.     (Bier.) 

not  cause  or  increase  pain.  If 
it  has  this  effect  it  Ls  improperly 
applied  or  is  unsuitable  for  the 
case  (Fig.  175). 

The  application  should  be 
limited  to  periods  of  one  to 
three  hours   daily  according  to 

The  application  of  passive    congestion:  A,  \)[\q  effcctS.^ 
the  alternate  point  for  the  application  of  the  ,._^,  .  > 

bandage,    in    order    to    avoid    atrophy  from  1  hc    aCtlOll    OI    tllC   VeUOUS    Or 

c^tinuous  pressure.     S.  the  rubber  bandage,  p^^^j^.g   cOngCStion   Is,  aCCOl'diug 

to  Bier,  as  follows : 

1.  It   increases   the   formation   of   fibrous   ti.ssue   and    induces 
hypertrophy  of  the  bones. 

2.  It   has    a    bactericidal    action    in    infectious    joint    disease, 
notably  tuberculosis. 


1  Bier,  Hyperiimie  als  Heilmittel,  Leipzia:,  1905. 


264  OR THOPEDIC  S UR GEE  Y 

3.  It  exercises  an  absorptive  effect  on  the  effused  products  of 
disease  and  on  new  formations  that  check  joint  motion. 

4.  It  reheves  pain  and  lessens  the  activity  of  progressive  joint 
disease. 

The  most  important  indication  for  passive  congestion  is  in  the 
treatment  of  tuberculous  disease. 

If  applied  for  disease  of  the  wrist-joint  it  is  unnecessary  to 
bandage  the  fingers,  as  the  finger-joints  are  usually  stiff  either 
from  disuse  or  from  adhesions  about  the  tendons — a  condition 
for  which  treatment  by  venous  congestion  is  indicated. 

Passive  congestion  for  tuberculous  joint  disease  should  be  sub- 
ordinated to  protective  treatment,  although  this  is  not  the  opinion 
of  Bier,  who  favors  motion  rather  than  fixation  of  the  diseased 
joint.  It  may  be  continued  indefinitely  according  to  its  effect. 
As  a  rule,  pain  is  lessened  by  the  treatment  and  muscular  spasm 
decreases.  This  latter  effect  is  in  part,  at  least,  explained  by  the 
constriction  of  the  muscles. 

Abscess  formation  or  appearance  at  least  is  apparently 
favored  by  the  congestion.  This  may  be  treated  by  aspiration 
or  incision  and  by  the  injection  of  the  iodoform  emulsion  if 
desirable. 

Passive  congestion  is  employed  also  for  the  treatment  of  chronic 
disability  following  injury,  for  chronic  disease,  such  as  rheu- 
matoid arthritis  or  other  affection  attended  by  infiltration  of 
tissues  and  by  deficient  circulation.  In  this  class  of  cases  the 
local  congestion  may  be  combined  with  massage. 

The  treatment  of  acute  infectious  processes  of  joints  and  other 
tissues  by  passive  congestion  has  now  come  into  general  use. 
Bardenheuer  is  one  of  its  most  enthusiastic  advocates.^ 

Active  Congestion. — Active  congestion  is  induced  by  the  local 
use  of  heat,  ordinarily  hot  dry  air. 

In  its  simplest  form  the  apparatus  consists  of  an  alcohol  lamp 
provided  with  a  long  metal  chimney  reaching  to  a  box  of  wood 
or  metal,  into  which  the  limb  is  inserted  through  openings  at 
either  end.  The  box  has  one  or  more  small  openings  for  the 
escape  of  air  and  moisture.  The  limb  is  usually  wrapped  in 
sheet  wadding,  and  ls  particularly  well  protected  from  the  parts 
of  the  box  which  may  come  in  contact  with  the  skin.  The  heat 
is  then  applied,  usually  to  about  250°  or  300°  F.,  for  from  thirty 
minutes  to  an  hour  daily.     The  degree  of  heat  is  indicated  by 

'  DeulHcheii  f.  Chir.,  XXXV.  Kongresa,  1906. 


TUBERCULOUS  DISEASE  OF  THE  BONES  AND  JOINTS       265 

a  projecting  thermometer,  and  it  is  regulated  by  the  comfort 
of  the  patient  and  by  the  observation  of  its  effects. 

Bier  prefers  simple  boxes  of  wood  of  various  shapes  suitable 
for  the  different  parts  of  the  body,  lined  with  packing  cloth  soaked 
in  a  solution  of  water  glass.  He  considers  these  as  efficacious 
as  the  complicated  and  expensive  appliances,  and  at  the  command 
of  all  who  desire  to  employ  the  treatment  (Fig.  162). 

The  effect  of  the  heat  is  to  induce  arterial  instead  of  venous 
hypersemia,  and  to  cause  profuse  local  and  general  perspiration. 
Active  hyperaemia  is  not  suitable  for  the  treatment  of  acute  or 

Fig.   177 


The  application  of  the  hot-air  box  for  inducing  active  congestion.  The  box  C,  the 
thermometer.  A,  a  metal  pipe  projecting  from  the  box,  into  which  the  chimney  of  the 
lamp  is  placed.     B,  lamp  chimney.     (After  Bier.) 

progressive  joint  disease.  It  exercises  a  dissolving  and  absorb- 
ing action  on  effused  material  and  on  the  tissues  of  new  forma- 
tion causing  limitation  of  motion  within  a  joint.  It  increases 
local  nutrition  and  it  relieves  pain.  It  is  especially  indicated  in 
the  treatment  of  local  disability  after  injury,  chronic  efl'usions 
into  joints,  rheumatoid  arthritis,  chronic  rheumatLsm,  and  the 
like  in  which  the  circulation  is  deficient. 

As  a  rule,  the  application  of  local  heat  should  be  supplemented 
by  massage.  The  profuse  general  pei-spiration  that  is  induced 
by  it  is  a  contraindication  in  weak  individuals. 


CHAPTER  VI. 

XOX-TFBERCULOUS  DISEASES  OF  THE  JOINTS. 

Syphilitic  Diseases  of  the  Joints. 

Tn  early  infancy  the  characteristic  syphihtic  disease  of  the 
bones  is  a  form  of  osteochondritis.  Painful,  sensitive  swellings 
appear  at  the  epiphyseal  junctions,  either  as  small,  hard  tumors 
or  as  general  enlargements,  resembling  those  of  rhachitis  (Fig. 
178).  As  a  rule,  several  epiphyses  are  involved,  more  often 
those  at  the  distal  extremities  of  the  bones  of  the  lower  limbs, 
and  in  these  cases  the  pain  and  discomfort  may  induce  an  appear- 
ance of  helplessness  of  the  part  called  pseudoparalysis  (Parrot). 

In  osteochondritis  there  is  a  multiplication  and  irregularity  of 
the  cartilage  cells  of  the  ossifying  layer  and  premature  calcifica- 
tion. As  a  result,  the  circulation  is  insufficient  and  necrosis  of 
a  part  of  the  cartilage  may  follow,  which,  acting  as  a  foreign 
body,  sets  up  inflammatory  changes  in  the  adjoining  parts.  The 
process  is  shown  by  a  zone  of  hard,  dry,  yellow  substance  in  the 
ossifying  layer,  adjoining  which  is  an  inflammation  of  the  tissues 
of  the  newly  formed  bone,  which  is  in  part  replaced  by  granu- 
lation .tissue.  If  the  disease  is  progressive,  ulceration  and  sup- 
puration may  follow;  the  cartilage  may  be  destroyed,  and  the 
epiphysis  may  be  separated,  causing  deformity  and  cessation  of 
growth.  The  neighboring  joint  is  usually  involved  in  the  dis- 
ease. In  the  milder  cases  there  is  a  simple  sympathetic  synovitis; 
in  the  advanced  class  a  destructive  arthritis.  In  one  case  seen 
recently  in  a  child  three  months  of  age  the  symptoms  of  pain  on 
motion  combined  with  slight  effusion  into  several  joints  were 
present  without  the  epiphyseal  enlargement.  The  aft'ection  may 
be  distinguished  from  rhachitis  by  the  accompanying  evidences  of 
inherited  syphilis,  by  the  irregularity  of  the  epiphyseal  involve- 
ments, and  by  the  age  of  the  patient  and  the  absence  of  the  other 
symptoms  of  rhachitis. 

In  the  later  manife.stations  of  hereditary  syphilis,  in  which  the 
bones  in  the  neighborhood  of  the  joint  are  involved  in  syphilitic 
osteoperiostitis,  the  joint  may  be  sympathetically  affected  or  the 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS 


267 


disease  may  actually  perforate  the  joint.  In  this  form  of  disease 
the  synovial  membrane  is  usually  hypertrophied  and  it  may 
interfere  with  the  function  of  the  joint.  The  fluid  is  increased 
in  quantity  and  the  affection  may  resemble  synovial  tuberculosis. 
A  slow,  chronic,  infiltrating  gummatous  form  of  disease  appear- 
ing in  later  childhood  may  simidate  very  closely  the  appearances 
of  so-called  white  swelling.  It  is  more  common  at  the  knee, 
but  other  joints  are  often  affected  as  well.  In  other  instances 
one  or  more  of  the  joints  may  be  involved  before  the  enlargement 
of  the  neighboring  bone  is  apparent,  the  symptoms  being  those 

Fig.   178 


Suppurative  syphilitic  epiphysitis  at  lower  ends  of  radius  and  tibia  in  an  infant  aged 
one  month.  The  child  died  shortly  after  the  drawings  were  made,  and  the  epiphj-ses  were 
found  lying  loose  in  purulent  cavities.     (Tubby.) 


of  chronic  synovitis.  A  common  manifestation  of  hereditary 
syphilis  is  keratitis.  In  a  series  of  77  cases  in  which  this  was 
present  there  was  involvement  of  the  joints  in  56  per  cent.,  the 
knee  being  most  often  affected.^ 

In  the  secondary  stage  of  acquired  syiMlis  pain  and  swelling 
of  the  joints,  resembling  rheumatism,  may  be  present,  and  in 
tertiary  syphilis  the  joint  may  be  involved  in  disease  of  the  neigh- 
boring bones,  or  the  joint  itself  may  be  primarily  implicated. 

^  Hippel,  Munch,  med.  Woch.,  No.  31,  1903. 


268 


ORTHOPEDIC  SUBGEBY 


In  most  instances  the  joint  affections  of  syphilis  are  explained 
by  the  history  and  by  the  other  signs  of  syphilitic  disease.  Spina 
ventosa  (Fig.  ISO),  which  is  classed  as  one  of  the  evidences  of 
syphilis,  is  far  more  commonly  of  tuberculous  origin,  as  is  illus- 
trated by  the  statistics  of  Karewski,^  of  157  cases,  in  which  but 
three  were  due  to  syphilis. 

Syphilitic  disease  of  the  joints  is  comparatively  rare  in  orthopedic 
clinics  as  contrasted  with  those  of  tuberculous  origin.     This  is  as 

Fig.   179 


Syphilitic  osteoperiostitis  of  the  tibial  resembhng  anterior  bow-leg.  This  is  the  most 
characteristic  manifestation  of  hereditary  syphilis.  It  induces  not  only  deformity  and  hy- 
pertrophy, but  elongation  of  the  bones  as  well. 

might  be  expected,  for  not  only  is  tuberculosis  far  more  common 
than  syphilis,  but  a  very  large  proportion,  according  to  Fournier, 
77  per  cent.,  of  the  syphilitic  children  are  stillborn  or  die 
shortly  after  birth.  Even  among  those  that  survive,  disease  of 
the  bones  or  joints  in  the  form  that  could  be  confounded  with 


'  Chir.  Krank.  des  Kindesalters. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        269 


tuberculosis,  is  uncommon  as  compared  with  its  other  manifesta- 
tions. 

Treatment. — Certain  writei-s  consider  hereditary  syphihs  to  be 
a  very  important  predisposing  cause  of  tuberculous  disease,  and  be- 


FiG.  180 


Fig.  181 


Hereditary  syphilitic  disease  of  the  meta- 
carpus and  phalanges. 


Hereditary  syphilitic  disease  of  the 
joints.  In  this  case  the  interior  of  the 
right  knee-joint  was  lined  with  hyper- 
trophied  folds  of  sjTiovial  membrane.  A 
complete  cure  followed  the  administration 
of  appropriate  remedies. 


lieve  that  many  cases  classed  as  tuberculous  are  in  reality  syphilitic, 
even  if  no  history  or  confirmatory  signs  of  syphilis  are  present. 
There  Ls  no  relial)le  evidence  to  support  this  view.  The  possi- 
bility of  the  syphilitic  taint,  remote  or  direct,  shoiUd  be  borne  in 


270  OE  THOPEDIC  SUBGEB  Y 

mind,  and  in  all  doubtful  cases   appropriate  remedies  should  be 
employed. 

In  general,  the  treatment  of  the  joint  affection  would  be  in- 
cluded in  the  general  treatment  of  the  disease  of  which  it 
is  a  complication.  If  the  joint  is  involved  in  a  destructive  pro- 
cess apparatus  to  ensure  rest  and  protection  is  indicated.  The 
removal  of  irritative  disease  in  the  neighborhood  of  a  joint  is 
sometimes  possible  in  older  subjects,  and  in  this  class  of  cases  an 
exploratory  mcision  for  inspection  of  the  joint  is  sometimes  advis- 
able (Fig.  181). 

Gonorrhoea!  Arthritis. 

Synonym. — Gonorrhoeal  rheumatism. 

So-called  gonorrhoeal  rheumatism  is  an  inflammation  of  a  joint 
caused  by  the  presence  of  gonococci.  It  is  said  to  complicate 
from  2  to  5  per  cent,  of  all  the  cases  of  gonorrhoea,  usually  ap- 
pearing in  the  later  stages  of  that  affection,  and  it  is  more  com- 
mon among  those  who  are  in  a  debilitated  condition. 

Distribution. — In  about  40  per  cent,  of  the  cases  it  is  mon- 
articular and  the  knee-joint  is  most  often  involved.  In  375 
cases  collected  by  Finger  the  distribution  was  as  follows:^ 

Knee 136         Shoulder 24 

Ankle 59  Hip 18 

Wrist 43         Jaw 14 

Finger-joints 35  Other  articulations      ....      21 

Elbow      ........        25  

375 

Bennecke^  has  tabulated  78  cases  recently  under  treatment. 
The  78  cases  occurred  in  56  patients,  of  whom  18  were  males, 
38  females.     The  distribution  was  as  follows: 

Knee 31  Shoulder 4 

Hip 8  Elbow 10 

Ankle 9  Wrist 6 

Other  joints  of  foot 6  Fingers 4 

78 

In  46  cases  recorded  by  Markheim^  one  joint  was  involved  in 
13  cases,  two  joints  in  12,  three  joints  or  more  in  18.  The  order 
of  frcfjuency  was  knee,  hip,  shoulder,  wrist,  and  elbow. 

Symptoms. — The  affection  is  usually  of  a  subacute  character. 
The  joint  becomes  swollen  and  there  is  discomfort,  and  particu- 
larly weakness,  and  stiffn(;ss  on  use.     If  the;  infection  is  more 

'  Taylor,  Venereal  Diseases,  p.  263. 

'■'  Die  Gon.  (iclenkentziinrlung  nach  beob.,  dor  (!liir.  liniv.  Klin,  in  dor  K.  Ciiarit6  zu  Ber- 
lin.    Hirsohwald,  Heriin,   1890. 

3  Deutsche  Archiv  f.  klin.  Med..  1!)02,  vol.  Ixxii.,  p.   180. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        271 

severe  there  may  be  local  heat,  pain,  and  infiltration  of  the  tissues, 
with  accompanying  muscular  spasm. 

In  all  the  forms  the  infiltration  of  the  subsynovial  tissues  of 
the  capsule  and  of  the  superficial  tissues  is  more  marked  than  the 
actual  effusion  within  the  joint.  The  more  serious  cases  are  char- 
acterized by  a  peculiar  a^dematous,  boggy  swelling  of  the  tissues, 
and  the  skin  is  hot,  sensitive,  and  glazed.  There  is  usually  in- 
tense pain  on  motion  of  the  limb  or  on  jar.  After  the  subsi- 
dence of  the  acute  symptoms  the  thickening  persists,  and  practical 
anchylosis  may  result. 

Gonorrhoeal  arthritis  has  been  divided  into  three  classes  accord- 
ing to  its  symptoms  and  physical  characteristics:  the  serous,  the 
serofibrinous,  the  purulent. 

The  serous  form  is,  as  its  name  implies,  a  simple  effusion  re- 
sembling other  forms  of  subacute  synovitis,  although  it  Is  of  a 
more  chronic  character. 

The  serofibrinotis  variety  Ls  the  so-called  plastic  type  of  inflam- 
mation. In  this  form  fibrin  is  deposited  upon  the  cartilage  and 
it  is  afterward  organized  by  the  growi;h  of  vessels  into  it  from  the 
synovial  membrane,  a  process  which  erodes  the  cartilage  upon 
which  the  granulations  rest.  The  folds  of  the  synovial  membrane 
adhere  to  one  another,  the  capsule  is  thickened,  and  ligaments  and 
tendons  may  be  involved  in  the  adhesive  inflannnation.  These 
changes  within  and  without  the  joint  may  seriously  impair  its 
function  after  the  cure  of  the  active  disease. 

The  'purulent  form  is  uncommon;  it  is  similar  in  its  character- 
istics to  suppurative  arthritis  from  other  causes.  It  is  attended 
by  great  local  heat,  pain,  and  swelling,  and  by  constitutional 
disturbance. 

In  orthopedic  clinics  gonorrhoeal  arthritis  Is  usually  seen  is 
its  later  stages  when  the  acute  symptoms  have  subsided.  In 
these  cases  swelling  and  pain  persist  in  many  instances,  and  in 
the  more  severe  class  motion  is  limited  or  the  limb  may  be  fixed 
in  an  attitude  of  deformity.  An  obstinate,  monarticular  painful 
swelling  of  a  joint  suggests  gonorrhoea,  and  its  presence  or  absence 
should  always  be  determined,  since  the  effective  treatment  of  the 
primary  cause  is  essential  to  the  cure  of  the  secondary  affection 
of  the  joint.  The  same  statement  is  true  of  painful,  pei-sistent 
affections  of  bui-s?e  and  tendon  sheaths,  and  of  obstinate  forms  of 
weak  foot. 

Fuller,  of  New  York,  has  reported  several  cases  in  which  cure 
of    persistent    disease    of    joints    and    tendon    sheaths    followed 


272  ORTHOPEDIC  SUBOERY 

direct  treatment  of  gonorrhoeal  disease  in  or  about  the  seminal 
vesicles. 

Treatment. — The  local  treatment  of  the  early  stage  of  this  form 
of  arthritis  is  rest  and  compression,  together  with  hot  or  cold  applica- 
tions, as  may  seem  to  be  indicated.  Ichthyol  ointment  in  a  pro- 
portion of  about  40  per  cent,  appears  to  relieve  the  pain  and  to 
stimulate  the  absorption  of  the  effusion.  If  the  symptoms  are 
acute  and  if  there  is  constitutional  disturbance,  the  joint  should 
be  aspirated,  and  if  the  examination  shows  the  effusion  to  be  sero- 
purulent,  it  should  be  treated  by  incision  and  drainage.  In  the 
chronic  form,  also,  when  the  capsule  is  distended  by  the  sero- 
fibrinous effusion,  incision  and  removal  of  the  contents  is  indicated. 

In  the  latter  stages  of  disease  of  the  ordinary  subacute  type, 
the  treatment  is  directed  to  the  absorption  of  the  effused  material 
within  and  without  the  joint,  and  to  the  restoration  of  functional 
activity.  The  use  of  hot  air,  massage,  passive  congestion,  the  hot 
and  cold  douche,  static  electricity  and  the  like  are  of  service 
in  stimulating  the  circulation.  If  the  limb  has  become  deformed, 
and  if  it  is  fixed  by  adhesions  and  by  contractions,  the  deformity 
may  be  corrected  by  forcible  manipulation  under  anaesthesia. 
And  it  may  be  stated  that  in  this  class  of  cases  restoration  of 
function  to  a  greater  or  less  degree  is  often  accomplished  by  this 
means. 

If,  however,  the  limb  is  fixed  in  the  proper  position  it  is  well 
to  postpone  forcible  measures  until  the  effect  of  the  massage  and 
gentle  passive  movements  have  been  observed. 

Functional  use  is  the  most  effective  restorative  treatment  after 
the  acute  symptoms  have  subsided.  This  is  made  possible  by  the 
employment  of  apparatus  which  limits  motion  to  the  degree  the 
joint  permits  without  causing  discomfort. 

Gonorrhoeal  Arthritis  in  Infancy. — This  complication  in  in- 
fancy is  usually  a  multiple  arthritis  of  a  pysemic  character.  In 
a  series  of  78  cases  of  gonorrhoeal  infection  treated  at  the  Babies 
Hospital  there  were  ten  cases  of  arthritis,  six  died  directly  from 
the  disease,  two  died  later  from  exhaustion,  and  in  the  two  remain- 
ing, recovery  secm(!d  improbable. 

Puerperal  Arthritis. — This  is  so  similar  in  its  characteristics 
to  gonorrhcx'al  arthritis  that  a  detailed  description  is  unnecessary. 
It  may  be  stated,  however,  that  puerperal  arthritis  is  usually  of 
a  more  severe  type  than  the  preceding  affection. 

I   Kiml,;ill,   Med.   Hocord,  Nov.   14,   1903. 


NON-TUBERCULOUS  DISEASES  OF  TEE  JOINTS        273 


Arthritis  Complicating  Infectious  Diseases. 

The  joints  may  be  involved  in  the  course  of  any  infectious  dis- 
ease. A  mild  form  of  arthritis,  often  involving  several  joints, 
is  common  after  diphtheria  or  scarlatina;  of  this  53  cases  have  been 
collected  by  Brunn,'  and  it  is  occasionally  observed  as  a  sequel 
of  pneumonia.  This  form  is  usually  of  a  more  severe  type  than 
the  preceding  forms. 

Brade^  has  reported  60  cases  of  joint  involvement  in  868  cases  of 
scarlatina  treated  in  St.  Jacob's  Hospital;  56  were  of  the  serous 
type;  4  were  of  the  suppurative  form,  causing  the  death  of  the 
patients.  In  but  8  of  the  cases  was  the  arthritis  limited  to  a 
single  joint. 

Arthritis  following  typhoid  fever  is  often  of  a  severe  and  de- 
structive type.  Keen^  has  tabulated  84  cases.  In  43  per  cent, 
of  these  the  hip-joint  was  affected  and  in  40  per  cent,  sponta- 
neous dislocation  occurred.  In  a  case  treated  recently  at  the 
Hospital  for  Ruptured  and  Crippled  there  had  been  a  destruc- 
tive arthritis  of  one  hip-joint,  spontaneous  displacement  of  the 
femur  on  the  other  side,  and  secondary  contractions  at  the  knees 
and  ankles,  so  that  the  patient  was  bedridden. 

Treatment. — The  treatment  in  all  forms  of  arthritis  compli- 
cating diseases  of  this  class  is  to  place  the  affected  joint  at  rest, 
to  apply  heat  or  cold  as  may  be  indicated  by  the  local  condition, 
and  to  prevent  the  secondary  distortions  that  lead  to  fixed  de- 
formities. The  presence  of  pus  is,  of  course,  an  indication  for 
immediate  incision  and  efficient  drainage;  thus,  in  all  doubtful 
cases  the  character  of  the  effusion  should  be  ascertained  bv 
aspiration. 

Spontaneous  dislocation,  which  is  comparatively  common  wjien 
the  hip-joint  is  suddenly  distended  with  fluid,  is  not  likelv  to  occur 
unless  the  limb  is  flexed  and  adducted.  This  attitude  should  be 
prevented  by  the  use  of  traction  or  support. 

The  after-treatment  has  been  indicated  already. 

Prognosis. — It  is  evident  that  the  immediate  reaction  to  bac- 
terial infection  and  the  final  results  will  vary  with  the  virulence 
of  the  infection,  the  natural  resistance  of  the  individual,  and  of 
the  part  involved.     According  to  Poynton  and  Paine^  the  bacteria 

1   Berlin,  klin.    Woch.,   No.    27,    1904.  -  Leipzig,  1903. 

'   SuFKical   Complicalion.s  and   Scrjuels  to  Typhoid   Fever. 
■•  Briti.sh  Medical  Journal,  Noveinber^l,  1902. 

18 


274  ORTHOPEDIC  SUB6EBY 

reach  the  syno^-ial  membrane  through  the  capillaries  of  the  areo- 
lar tissue,  beneath  the  endothelium,  which  if  uninjured  serves 
as  a  barrier  to  protect  the  joint  cavity.  If  the  joint  is  not  actually 
involved  the  restriction  to  motion  will  depend  upon  thickening 
of  the  tissues  of  the  joint  and  upon  disuse  of  the  muscles.  In 
such  cases  the  prognosis  is  good.  If,  however,  the  interior  of 
the  joint  is  invaded  by  a  process  that  causes  adhesions,  and  partial 
destruction  of  the  cartilaginous  surfaces,  anchylosis  is  likely  to 
follow. 

Marsh^  divides  infectious  arthritis  into  four  classes: 

1.  Simple  infiltration  of  the  subsynovial  tissues  and  slight 
synovitis. 

2.  Effusion  of  fluid  into  the  synovial  sac — ^synovitis. 

3.  Infiltration  of  the  periarticular  tissues — plastic  inflamma- 
tion. 

4.  General  destructive  arthritis.  In  the  first  and  second  classes 
complete  recovery  may  be  anticipated.  In  the  third  class  a  vary- 
ing degree  of  functional  disability  is  to  be  expected.  In  the  last 
it  is  inevitable. 

Acute  Arthritis  of  Infancy. 

A  form  of  acute  suppurative  arthritis  primarily  within  the  joint 
or  more  often  secondary  to  disease  of  the  neighboring  epiphysis 
is  not  uncommon  in  infancy. 

Etiology. — The  disease  is  usually  caused  by  staphylocccci,  occa- 
sionally by  other  forms  of  infection.  (See  Gonorrhoeal  Arthritis.) 
In  the  early  weeks  of  life  it  may  follow  infection  at  the  umbilicus 
or  other  surface  lesion.  It  may  be  secondary  to  one  of  the  exan- 
themata or  to  gonorrhoea,  but  in  many  instances  the  origin  is 
not  apparent. 

Falls  or  blows  upon  the  part  appear  to  be  predisposing  causes. 

Townsend^  tabulated  73  cases  of  acute  arthritis,  18  of  which 
were  personal  observations.  To  these  I  am  able  to  add  12  others, 
making  a  total  of  85  cases.  In  64  of  these  the  infection  was 
monarticular;  in  21  more  than  one  joint  was  involved.  The 
distribution  was  as  follows : 

Hip-joint 46  =  63  per  cent. 

Knee-joint .     32  =  37 

Other  joints 8  =  10 

The  sex  was  specified  in  Gl  cases:  males,  38;  females,  23.     It 

'   IJriti.sh  Medical  Journal,  December,   1902. 

8  American  Journal  of  the  Medical  Sciences,  January,  1890. 


NON-  T  TIBER  C  UL  0  US  DISEASES  OF  THE  J  0  IN  TS        275 

is  of  interest  to  note  that  in  all  reported  cases  the  males  out- 
number the  females.  In  285  cases,  including  the  above  and 
others  reported  by  Gonser,  Dennne,  Liicke,  Billroth,  Schede,  and 
Miiller,  the  proportion  was  nearly  3  to  1/ 

Symptoms. — If  the  infection  is  severe  there  ls  immediate  local 
heat,  redness,  swelling  and  (rdema,  great  pain,  and  correspond- 
ing constitutional  disturbance.  But  in  many  instances  the  local 
and  general  symptoms  are  less  marked,  the  child  Ls  fretful,  and 
the  evident  discomfort  caused  by  motion  at  the  affected  joint  is 
mistaken  for  result  of  injury  or  rheumatism.  In  this  class  of  cases 
the  patient  is  not,  as  a  rule,  seen  until  several  weeks  after  the 
onset  of  the  affection.  The  joint  Ls  then  somewhat  infiltrated 
and  enlarged,  motion  is  painful  and  restricted,  and  the  general 
appearances  are  very  similar  to  tuberculous  disease.  There  are 
also,  without  doubt,  even  milder  forms  of  synovial  infection 
from  which  recovery  is  rapid  and  practically  complete.  These 
cases  are  usually  classed  as  monarticular  rheumatLsm.  Similar 
symptoms  may  be  induced  directly  by  injury;  motion  causes  pain; 
the  limb  is  flexed  and  persistent  deformity  may  result  unless  pro- 
tection Ls  assured. 

Treatment. — The  treatment  of  suppurative  arthritis  Ls,  of 
course,  free  incision  and  efficient  drainage.  In  all  cases  the  joint 
must  be  fixed,  preferably  by  a  light  wire  splint,  during  the  active 
stage  of  the  disease.  An  apparatus  is  usually  required  to  prevent 
deformity  or  to  support  the  weak  limb  when  the  patient  begins  to 
walk. 

Prognosis. — If  the  arthritis  is  a  primary  disease  within  the 
joint  complete  recovery  may  follow  evacuation  of  the  pus,  but, 
as  a  rule,  the  neighboring  epiphyseal  junction  is  diseased,  sup- 
puration Ls  prolonged,  and  a  part  of  the  epiphysis  is  destroyed 
before  the  disease  ccmes  to  an  end;  thus,  subluxation  or  dis- 
placement with  subsequent  deformity  and  less  of  growth  are  the 
usual  results  of  this  form  of  disease.  At  the  hip-joint,  for  ex- 
ample, the  laxity  of  the  ligaments  and  the  upward  displacement 
of  the  femur  that  follow  destruction  of  the  head  of  the  bone  cause 
symptoms  that  in  later  life  are  often  mistaken  for  those  of  con- 
genital dislocation. 

In  some  of  the  cases  there  is,  in  addition  to  the  arthritis,  an 
osteomyelitis  of  the  shafts  of  one  or  more  of  the  bones.  These 
cases  are  usually  fatal,  or,  if  the  patient  survives,  there  is  usually 
necrosis  of  the  affected  bones  and  consequently  extreme  deformity 

'  Gonser,  Jahrbucli  f.   Kiiulerheilk.,  July,   1902. 


276 


OR THOPEDIC  S UB GERY 


In  the  cases  reported  by  Townsend  the  death-rate  was,  In  the 
monarticular  form,  IS  per  cent.;  ui  the  muUiple  form,  73  per 
cent. 

In  a  total  of  122  cases  of  all  varieties  tabulated  by  Hoffmann, 
the  death-rate  was  46  per  cent.     In  87  the  affection  was  confined 


Ftg.  182 


Deformities  re.sulling  from  infectious  osteomyclili.s. 

U)  one  j<jint;  in  the  remainder  from  two  to  hve  joints  were  in- 
volved.^ 

Acute  Tuberculous  Arthritis. — In  early  infancy  forms  of 
acute  tuberculous  disease,  esjx-cially  at  the  knee-joint,  may  simu- 
late closely  infectious  arthritis.     The  joint  may  become  swollen, 

'   Medical   Bulletin,   Wn«hingli;n   University,  September,  1902. 


NON-TUBERCULOVS  DISEASES  OF  THE  JOINTS        277 

hot,  and  sensitive  to  pressure,  and  the  onset  may  be  sudden  and 
accompanied  by  constitutional  disturbance.  Such  cases  are  more 
often  observefl  in  the  children  of  mothers  suffering  from  advanced 
disease  of  the  lungs. 


Acute   Osteomyelitis. 

Infectious  osteomyelitis  Is  most  common  in  adolescence  and  the 
extremities  of  the  bones  in  the  neighborhood  of  the  epiphyseal 

Fig.   183 


Tuberculous  osteomyelitis  localized  in  the  lower  extremities  of  the  radius  and  ulna,  demon- 
strated by  the  x-ray  and  removed  before  the  wrist-joint  was  involved. 

cartilages  are  most  often  involved.  Trendel,  from  the  histories  of 
105S  cases  in  Bruns^  clinic,  states  that  it  is  most  common  in  the 
period  from  the  thirteenth  to  the  seventeenth  year.  In  one-half  the 
cases  the  femur  was  involved;  in  one-third  the  tibia. 

The  symptoms  are  local  sensitiveness  of  the  bone,  pain,  and 
constitutional  disturbance.  The  neighboring  joint  is  usually  dis- 
tended by  a  sympathetic  synovitis,  and  the  overlying  tissues  are 
usually  infiltrated.  The  treatment  consists  in  immediate  opening 
of  the  bone  at  the  suspicious  pohit,  in  order  to  relieve  the  tension 

1  Beit.  zur.  klin.  Chir..  Bd.  xli.  p.  3. 


278 


ORTHOPEDIC  SURGERY 


and  to  establish  drainage.  In  certain  instances  the  jomt  itself 
may  be  directly  involved  in  the  disease.  This  may  be  inferred  if 
the  symptoms  do  not  subside  after  the  bone  has  been  opened. 
In  doubtful  cases  the  joint  should  be  aspirated  for  the  purpose  of 
bacteriological  examination,  but  even  if  pathogenic  bacteria  are 
present  the  treatment  by  incision  or  other^^'Lse  must  be  decided  on 
the  clinical  symptoms. 

For  in  cases  of  this  character  bacteria  are  often  found  not  only 
in  affected  joints,  but  m  the  blood,  and  in  the  marrow  of  the 

Fig.  184 


^^H^Hj 

p^ 

BT 

■ 

^^^^^B      'W^'%r   . 

1 

1 

W-    iini,,                          f    ■■  ■ 

1 

■■  ■                                                           /■ 

H 

hiiTiiiirj 

^^^^Im&  ^  ^  1 

1 

Lo3S  of  gro-.vth  f(jllowina:  osteomyelitis  of  the  tibia,  nepessitating  removal  of  part  of 

the  shaft. 

unaffected  bones  also.  The  investigations  of  FraenkeP  show  that 
specific  micro-organisms  are  present  in  the  red  marrow  of  the 
vertebrae,  in  the  ribs  and  elsewhere  in  every  form  of  infectious 
disease,  and  that  they  may  be  found  here  even  when  they  are  ab- 
sent in  the  1;1(jo(1.  In  the  blood,  according  to  Bertelsmann,^  they 
may  be  found  in  about  one-third  of  all  cases  of  surgical  infection 
and  far  more  often   when  l)oncs    or  joints  arc   involved.     In  a 


'  Mit.  a.  (I.  (?''en//«ebieten  d.  Med.  u.  Chir.,  Mil.  xii. 
-  Deutsch.  Zeit.  f.  Chir.,  Bd.  Ixxii.  p.  209. 


NON-TUBEBCULOUS  DISEASES  OF  THE  JOINTS       279 

series  of  48  positive  results  streptococci  were  found  in  68  per 
cent.,  staphylococci  in  30  per  cent. 

The  prognosis  in  neglected  cases  is  bad :  for  example,  in  54  cases 
of  acute  osteomyelitis  of  the  upper  extremity  of  the  femur,  in  all 
but  seven  of  which  the  joint  was  involved,  the  death-rate  was  60 
per  cent.' 

Localized  osteomyelitis  in  the  neighborhood  of  a  joint  may 
simulate  tuberculous  disease  of  the  joint.  The  onset  of  the 
affection  is,  however,  more  abrupt,  the  surrounding  tissues  are 
infiltrated,  and  the  symptoms  are  usually  more  acute  than  in  the 
latter  affection.  In  this  class  of  cases  of  the  subacute  type  the 
lesions  are  often  multiple,  fresh  foci  appearing  at  intervals  for 
an  indefinite  time.  The  treatment  of  choice  when  the  affection 
is  localized  is  the  operative  removal  of  the  diseased  area,  which 
is  indicated  by  local  sensitiveness,  and  which  in  many  instances 
may  be  demonstrated  by  the  a:-ray.  One  should  be  as  sparing 
of  the  bone  as  possible  because  of  the  danger  of  retardation  or 
irregularity  of  growth  that  almost  always  follows  the  loss  of 
even  a  moderate  amount  of  growing  tissue  The  iodoform  filling 
of  Mosetig-Moorhof,  p.  261,  may  be  used  with  advantage  in  this 
class  of  cases. 


Osteoarthritis  and  Rheumatoid  Arthritis.      Arthritis 
Deformans.    Rheumatic  Gout. 

Under  these  titles  are  included  a  group  of  chronic  diseases  of 
the  joints  whose  etiology  is  obscure.  At  the  present  time  these 
diseases  are  usually  classed  as  varying  manifestations  of  one 
pathological  process,  and  the  titles  are  usually  considered  as 
synonymous. 

Clinically,  however,  the  characteristic  types  differ  markedly 
from  one  another.  In  one  form  bone  destruction  is  combined 
with  bone  formation,  and  the  final  result  is  an  irregular  solid 
enlargement  of  the  joint,  usually  combined  w^th  distortion  of  the 
limb. 

It  has  been  suggested  by  Goldthwait  that  the  term  osteo- 
arthritis should  be  applied  to  this  type. 

The  second  form  resembles  somewhat  rheumatism  in  its  course 
and  distribution.  The  disease  is  primarily  of  the  soft  parts  of 
the  joint,  the  bone  is  only  secondarily  and  superficially  involved, 

^  Gyot,  Rev.  des  Chir.,  xxiv.,  Nos.  2  and  4. 


280 


ORTHOPEDIC  SURGERY 


and  the  final  result  is  limited  motion  or  anchylosis  without 
enlargement  of  the  joint.  This  form  is  sometimes  classed  as 
atrophic  to  distinguish  it  from  the  former  or  hypertrophic  variety 
of  arthritis  deformans,  but  the  term  rheumatoid  arthritis  seems 
to  be  preferable,  as  indicating  that  the  two  varieties  of.  chronic 


Fig.    185 


Osteoarthritis.  The  liyijertrophy  of  the  extieiiiit ie.s  of  the  bones  of  the  terminal  phalanges 
(Heberden's  node.s)  in  accompanied  by  eroKion  of  the  cartilage.  The  second  interphalan- 
geal  joint  of  the  second  finger  shows  hypertrophy,  combined  with  destruction  and  lateral 
displacement.     (See  Fig.   180.) 


joint   disease   are  distinct   and    do   not   represent    stages   of  one 
general  affection. 

Pathology  of  Osteoarthritis.  'J'lie  effects  of  the  disease  are 
most  noticealile  in  the  cartilage,  which  becomes  fil)rillated  and 
destroyed  in  the  parts  subjected  to  greatest  pressure,  while  it 
is  thickened  and  heaped  up  into  irregular  layers  at  the  periphery, 
as  if  under  the    influence    of  pressure  it  had   been  squeezed  out 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS         281 

from  the  interior  of  the  joint  (Fig.  187).  The  process  is  sup- 
posed to  consist  in  a  miiltipHcation  of  the  cartilage  cells  which 
in  the  free  portion  of  the  cartilage  escape  into  the  joint, 
while  in  those  parts  covered  by  synovial  membrane  they 
are  retained.  When  the  cartilage  disappears  the  bone,  de- 
prived of  its  natural    protection,  is    worn  away,  and    under  the 

I'IG.     list) 


Rheumatoid  (atropliic)  arthritis.     Slight  superficial  erosions  of  the  bones  are  to  be 
seen  at  several  of  the  joints.     Contra.st  with  osteoarthritis. 

influence  of  pressure  and  friction  it  becomes  increased  in  den- 
sity and  hardness,  "eburnated."  Meanwhile  the  irregular  pro- 
jections of  cartilage  at  the  periphery  become  in  part  ossified, 
and  this,  together  with  a  formative  periostitis  of  the  atljoining  bone, 
causes  the  irregular  bony  enlargement  characteristic  of  the  disease. 
The   contour   of    the    bones    and  their  mutual    relation    to   one 


282  ORTHOPEDIC  SURGERY 

ariother  are  changed.  The  SMiovial  membrane  becomes  hyper- 
trophied  and  its  \\[\\,  some  of  which  may  contain  cartilaginous 
n:diiles,  project  into  the  joint  in  shaggy  fringes.  These  may  be 
detached  from  time  to  time  and  may  form  loose  bodies  within 
the  capsule.  The  s}Tiovial  fluid  may  be  greatly  increased  in  quan- 
tity distending  the  capsule,  or,  communicating  with  bursa;,  it  may 
form  cysts,  as  is  sometimes  observed  at  the  knee-joint.  But  more 
commonly  the  fluid  is  decreased  in  amount.  The  ligaments  are 
weakened  and  destroyed,  and  the  tendons  about  the  joint  become 
adherent  to  their  sheaths  and  to  the  neighboring  tissues.  The 
muscles  atrophy  and  become  contracted  and  structurally  shortened 
in  accommodation  to  the  deformity. 

Etiology  of  Osteoarthritis. — Little  that  is  positive  is  known 
of  the  etiology  of  osteoarthritis.  Two  facto i-s  are  sufficiently 
evident.  These  are  age  and  injury  or  overstrain.  The  wearing 
out  of  the  joint  is  suggested  by  the  appearances,  and,  as  is  well 
known,  similar  changes  in  slight  degree  are  not  uncommonly 
found  in  the  joints  of  laborers  of  middle  age.  So,  also,  similar 
changes  may  follow  injury,  particularly  fracture  at  the  hip-joint. 
Lessened  local  and  general  resistance  are,  of  course,  predisposing 
causes.  In  locomotor  ataxia,  a  disease  accompanied  by  loss  of 
sensation  and  by  diminished  control  of  movement,  the  nutrition 
of  the  joint  is  lowered  and  its  natural  safeguards  against  injury 
and  overwork  are  removed.  Joint  disease  (Charcot's  disease)  of 
the  character  of  osteoarthritis  in  such  instances  is  undoubtedly 
an  indirect  effect  of  disease  of  the  nervous  apparatus,  but  it  by 
no  means  follows  that  such  or  any  disease  of  the  nervous  system 
is  necessary  to  explain  the  lesions  of  the  ordinary  form.  It  may 
be  mentioned  in  this  connection  that  a  form  of  disease  of  similar 
character  is  very  common  among  domestic  animals  in  old  age. 
It  has  been  suggested,  and  it  is  probably  true,  that  defective 
assimilation  may  be  a  causative  factor  in  both  man  and  animals. 

Symptoms. — In  its  typical  form  osteoarthritis  is  an  affection 
of  middle  life  and  of  old  age.  It  may  be  confined  to  a  single 
joint,  and  in  these  cases  one  of  the  larger  joints  of  the  lower  ex- 
tremity is  more  often  affected,  particularly  the  hip  or  knee.  As 
a  rule,  however,  several  joints  are  involved  to  a  greater  or  less 
degree.  Its  onset  is  usually  insidious,  and  the  progress  is  slow, 
accompanied    by   remission   of   the   symptoms. 

These  symptoms  are  usually  pain,  discomfort  in  changing  from 
one  position  to  another,  "creaking"  sensations  in  the  affected 
joints,    gradually    increasing    local    enlargement,    limitation    of 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        283 

motion,  and  distortion  of  the  limb.  Typical  examples  are  found 
in  the  hip-joint  (malum  coxse  senile)  and  knee,  and  these  are 
described   elsewhere. 

Heberden's  Nodosities.— Although  typical  osteoarthritis  may 
be  confined  to  one  or  more  of  the  larger  articulations,  it  Is  often 
accompanied  by  enlargement  of  the  joints  of  the  fingei-s.  It 
should  be  stated,  also,  that  there  is  a  form  of  osteoarthritis  of 
comparatively  slight  importance  in  which  the  disease  is  confined 
to  the  joints  of  the  fingers.     The  bases  of  one  or  more  of  the 

Fig.    187 


Osteoarthritis,  from  the  Museum  of  the  College  of  Physicians  ami  Surgeons,  New  York. 


distal  phalanges  become  enlarged  (Heberden's  nodosities),  and 
the  fingers  become  somewhat  stifT  and  painful,  the  pathology 
being  very  similar  to  that  already  described.  Gradually  other 
phalangeal  joints  become  involved  until  the  fingers  become  de- 
formed and  function  is  somewhat  interfered  witii.  The  dis- 
ease is  slowly  progressive,  pain  lessening  as  the  enlargement 
and  stiffness  become  more  apparent.  When  the  tlisease  liegins 
in  this  manner  the  larger  joints  are  not  often  implicated.  It 
is  interesting  to  note,  however,  that  this  form  of  disease  is  far 


284  ORTHOPEDIC  SVRGERY 

more  common  in  women  than  in  men,  and  it  may  be  accompanied 
by  disease  of  the  larger  joints  of  the  nature  of  rheumatoid 
(atrophic)  arthritis  (Fig.  186). 

Treatment. — In  general,  this  should  be  directed  to  the  im- 
provement, if  possible,  of  the  condition  of  the  patient.  The  daily 
routine  should  conform  to  what  the  personal  experience  of  the 
patient  shows  to  be  that  best  adapted  to  the  disability.  The 
local  nutrition  may  be  maintained  by  massage,  electricity,  and 
the  like.  Deformity  may  be  prevented  and  pain  may  be  relieved 
by  regulating  the  strain  to  which  the  weak  part  is  subjected  if 
practicable  by  the  use  of  apparatus.  In  certain  instances  opera- 
tive removal  of  villous  proliferations  of  the  synovial  membrane  or 
of  solid  projections  that  interfere  with  movement  may  be  of  ser- 
vice. (See  Spondylitis  Deformans  and  Osteoarthritis  of  the  Hip 
and  Knee.) 

Rheumatoid   or  Atrophic  Arthritis. 

Rheumatoid  arthritis  differs  from  the  preceding  type  in  that  it  is 
rather  an  affection  of  childhood  and  of  early  adult  life  than  of 
old  age.  It  is  more  common  among  females  than  males.  It  is 
more  acute  in  its  onset,  more  rapidly  progressive,  and  mare  general 
in  its  distribution  than  osteoarthritis. 

In  typical  osteoarthritis  the  cartilage  is  worn  away  at  the  centre 
of  the  joint,  heaped  up  at  the  periphery  and  the  underlying  bone 
is  involved  at  an  early  stage  of  the  disease.  In  typical  rheumatoid 
arthritis  the  affection  is  primarily  of  the  fibrous  coverings  and  of 
the  membranes  of  the  joint,  and  the  cartilage  is  destroyed  in  the 
later  stages  by  a  pannus-like  growth  from  the  periphery.  There 
is  secondary  erosion  of  the  cartilage  and  of  the  underlying  bone 
unaccompanied  by  the  hypertrophy  characteristic  of  the  preceding 
disease.  In  rheumatoid  arthritis  a  spindle-shaped  enlargement  of 
the  finger-joints  is  common,  but  the  a--ray  picture  will  not  show 
irregular  bone  formation  as  in  typical  osteoarthritis  (Heberden's 
nodosities),  but  a  normal  ontour  or  at  most  superficial  erosions 
of  the  bones  entering  int)  the  formation  'of  the  joint.  The 
second  interphalangeal  joints  are  usually  involved  primarily. 
There  is  usually  flexion  contraction,  and  in  many  instances  general 
deviation  of  the  fingers  toward  the  ulnar  side.  In  younger  sub- 
jects, particularly  in  the  class  of  cases  in  which  the  onset  of  the 
di-sease  is  acute,  and  in  which  there  is  considerable  effusion, 
there  may  be  subluxation  or  actual  luxation  of  the  phalanges. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        285 

more  often  at  the  metacarpal  articulations.  In  such  instances 
motion  is  preserved  in  the  affected  joints. 

In  typical  cases  the  final  result  in  any  joint  is  either  anchylosis 
or  limited  motion  accompanied  by  flexion  deformity.  There  Ls,  of 
course,  general  atrophy  of  the  long  bones  corresponding  in  degree 
t©  the  functional  disability  that  is  present. 

The  onset  of  rheumatoid  arthritis  may  be  acute,  resembling 
rheumatism,  many  joints  being  involved  simultaneously.  It  may 
be  subacute  and  even  limited  primarily  to  a  single  joint. 

The  larger  joints  may  be  involved  before  those  of  the  hands, 
or  vice  versa.     In  childhood  the  disease  often  begins  in  one  of 

Fir..    188 


Rheumatoid  arthritis  in  a  child,  showing  the  characteristic  deformity.     Nearly  every 
joint  in  the  body  is  involved. 


the  larger  joints,  causing  stiffness,  deformity,  and  pain  on  motion. 
There  is  usaally  some  local  heat  and  infiltration,  increasing  and 
diminishing  according  to  the  strain  or  injury  to  which  the  joint 
may  be  subjected.  In  cases  of  this  character  the  affection  is 
usually  mistaken  for  tuberculous  disease  until  the  involvement 
of  other  joints  indicates  the  true  character  of  the  affection.  As 
a  rule,  the  affection  is  progressive  in  character,  both  locally  and 
generally.  The  range  of  motion  in  the  affected  joint  becomes 
more  and  more  restricted,  the  limb  becomes  flexed,  and,  finally, 
there  is  practical  anchylosis,  usually  due  to  adhesions  and  con- 
tractions within  and  without  the  joint.     In  those  cases  in  which 


286 


ORTHOPEDIC  S UEGER Y 


the  cartilage  is  in  part  destroyed  bv  the  growth  of  granulation 
tissue  from  the  periphery  there  may  be  actual  bony  union.     In 


Fk;.    1S9 


Still's  form  of  polyarthritis,  showing  the  general  atrophy,   the  enlarged  joints,   and  the 
promirence  of  the  abdomen,  due  to  amyloid  degeneration  of  the  liver  and  spleen. 

many  instances  the  spine  becomes  rigid,  including  the  occipito- 
axoid  articulations,  and  practically  every  joint  of  the  body  may  be 
finally  involved,  so  that  the  patient  is  bedridden  and  helpless. 

Fig.    190. 


The  hands  m  the  case  shown  in  the  preceding  figure. 


The  disease  is  more  serious  and  mon;  rapidly  progressive  in 
the  young  tluin  in  older  subjects.  Tli(!re  are  periods  of  remis- 
sion and  of  exacerbation.  In  some  instances  the  disease 
appears  to  come  definitely  to  an  end,  leaving  the  stiffened  joints. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        287 

and    occasionally    complete    recovery   takes    place,    but    this    is 
unusual. 

A  peculiar  forjn  of  the  affection,  first  described  l)y  Still,^  occurs 
in  childhood.  This  begins  usually  in  one  or  more  of  the  larger 
joints.  As  a  rule,  it  progresses  rapidly,  and  it  is  accompanied 
by  enlargement  of  the  lymphatic  glands,  particularly  those  of 
the  inguinal  region  and  axilla,  and  of  the  liver  and  spleen.  There 
is,  as  a  rule,  moderate  effusion  into  the  joints  and  thickening  of 
the  overlying  tissues.  As  the  muscular  atrophy  is  extreme,  the 
joints  appear  by  contrast  very  much  enlarged.  The  final  out- 
come of  the  disease  is  anchylosis  and  deformity,  as  in  the  ordinary 
form.     Occasionally  complete  recovery  occurs. 

Although,  as  has  been  indicated,  typical  cases  of  rheumatoid 
arthritis  differ  so  essentially  from  osteoarthritis  as  to  be  classed 
as  a  distinct  disease,  yet  there  are  types  that  it  is  difficult  to  classify 
as  the  one  or  the  other,  and  in  certain  instances  the  two  forms 
may  be  combined  in  one  individual. 

Etiology.^ — Of  the  etiology  of  rheumatoid  arthritis  little  is  known. 
Certain  aspects  of  the  disease  resemble  closely  those  caused  by 
infection  from  without.  This  is  particularly  noticeable  in  those 
cases  in  which  the  disease  begins  in  one  or  more  of  the  larger 
joints.  On  the  other  hand,  infectious  joint  disease  of  the  ordi- 
nary form  is  not  slowly  progressive,  as  is  rheumatoid  arthritis  in 
its  typical  form.  It  is  probable,  however,  that  certain  forms  of 
infectious  arthritis  of  a  mild  character  are  included  in  what  is 
now  known  as  rheumatoid  arthritis.  Autoinfection,  due  to  defec- 
tive assimilation,  is  probably  a  predisposing  and  exciting  cause,  as 
it  is  well  known  that  this  aggravates  the  symptoms  of  the  disease 
when  it  is  once  established. 

Contributing  causes  are  apparently  an  inherited  predisposition 
or  a  lack  of  vital  resistance  due,  it  may  be,  to  overwork  or  strain, 
mental  or  physical,  and  exposure  to  cold  or  wet. 

Treatment. — In  general,  this  must  be  directed  to  inipr>)ving 
the  condition  of  the  patient  by  the  regulation  of  the  diet,  which 
must  be  nourishing  and  easily  assimilated.  Exposure  to  cold 
and  wet,  and  overexertion  must  be  avoided.  The  use  of  static 
electricity,  the  hot-air  and  the  electric-light  baths,  as  general  and 
local  stimulants,  are  of  service.  Ichthyol  ointment,  the  cautery, 
and  the  like  may  be  employed  locally.  If  the  joints  are  sensitive 
motion  should  be  restricted  to  the  painless  area  by  apparatus. 
Passive  motion  or  massage  that  increases  the  pain  or  discomfort  is 

'  Medico-Chirurg.  Transaclious,  1S97. 


288 


ORTHOPEDIC  SURGERY 


harmful,  but  motion  should  be  encouraged  when  the  disease  is 
quiescent.  Contraction  deformity  may  be  overcome  by  forcible 
manipulation,  and,  if  necessary,  by  tenotomy  when  the  disease  is 
quiescent.  Excision  of  an  anchylosed  joint,  as  of  the  lower  jaw 
or  elbow,  may  re-establish  painless  motion/ 

The  treatment  of  infectious  arthritis  is  discussed  elsewhere. 
It  may  be  that  a  primary  infection  of  a  single  joint  may  be  the 
starting  point  of  multiple  arthritis.  In  such  cases  operation  with 
the  aim  of  remoymg  the  focus  of  infection  may  be  considered. 

It  may  be  noted  as  of  interest  that  what  appears  to  be  typical 
rheumatoid  arthritis  in  childhood  may  be  induced  apparently  by 


Fici.    IPl 


Atrophic  arthritis  in  a  child  affecting  tlie  joints  and  the  spine,  progressive  in  char- 
acter, accompanied  by  enlargement  of  the  lymphatic  glands.  The  attitude  of  the  head  is 
characteristic  of  suboccipital  disease.     The  case  is  apparently  one  of  the  Still  type. 

infectious  disease,  such  as  diphtheria  for  example,  and  that  im- 
provement, or  even  disappearance,  of  the  local  symptoms  may 
follow  intercurrent  attacks  of  scarlatina  or  measles.  It  is  possible, 
therefore,  that  scrum-therapy  may  be  employed  in  the  future. 


Gout. 

Gout  is  comparatively  of  slight  importance  from  the  orthopedic 
standpoint.     It    affects    more    particularly    those    of    middle    life 

I  Whitniaii,   Medical   liecord.  April  IS,  1903. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS       289 

and  it  is  characterized  by  acute  inflammatory  attacks  followed  by 
deposits  of  urate  of  sodium  on  or  about  the  articular  surfaces 
of  the  affected  joints.  After  repeated  attacks  the  cartilage  and 
the  bone  may  be  in  part  destroyed,  and  the  joint  may  be  enlarged 
by  deposits  in  the  periarticular  tissues  and  by  the  inflammatory 
thickening  of  the  neighboring  joints.  The  joints  most  often 
involved  are  that  of  the  great  toe,  the  ankle,  knee,  and  the  joints 
of  the  finsers.  If  the  feet  are  weakened  or  distorted  as  the  effect 
of  gout,  a  proper  support  to  tlistribute  the  weight  more  generally  on 
the  sole  is  often  of  service.  The  operative  removal  of  unsightly 
deposits  about  joints  may  be  considered  also.  The  general  treat- 
ment of  the  patient  is  of  course  of  the  first  importance. 

Rheumatism. 

Certain  forms  of  rheumatism,  so  called,  are  of  interest  from  the 
orthopedic  standpoint,  notably  those  forms  that  affect  the  fibrous 
tissues  and  that  lead  to  permanent  changes  in  the  joints — "plastic 
rheumatism."  Undoubtedly  monarticular  arthritis  is  usually  due 
to  direct  infection  from  without,  as  are  certain  forms  of  poly- 
arthritis. Notably  those  that  follow  infectious  diseases.  There  are 
other  forms  sucli  as  are  characteristic  of  rheumatoid  arthritis,  of 
gout  and  die  like  which  can  not  be  thus  accounted  for  and  in 
which  defecitve  assimilation  and  lessened  resistance  of  the  tissues 
must  be  considered  the  important  factors. 

Haemophilia. 

Haemophilia  is  apparently  a  congenital  weakness  of  the  blood- 
vessels which  is  transmitted  through  females  to  males.  In  one 
family  under  observation  since  1827,  through  four  generations 
(207  members),  there  were  37  "bleeders,"  all  males;  33  per  cent, 
of  the  male  descendants.  Eighteen  died  from  the  effects  of 
hemorrhage,  nearly  all  in  chidlhood.^  In  a  family  known  to  the 
writer  all  the  males,  three  in  number,  died  of  hemorrhage,  two 
having  hved  to  adult  age. 

Hemorrhage  into  a  joint  in  this  class  is  not  uncommon,  the 
knee-joint  being  most  often  involved.  As  a  rule,  it  is  the  result 
of  injury,  and  if  the  peculiarity  of  the  patient  is  known  the 
nature  of  the  effusion — hemorrhagic— is  hardly  doubtful,  particu- 

'  Deutsch.  Zeit.  f.  Chir.,  Bd.  Lxxvi, 

19 


290  ORTHOPEDIC  SURGERY 

larlv  as  there  is  in  many  instances  discoloration  of  the  skin,  either 
over  the  joint  or  elsewhere.  In  some  instances  there  is  no  history 
of  traumatism,  and  the  swelling  may  be  accompanied  by  fever. 
This  is  probably  the  effect  of  the  hemorrhage  rather  than  its  cause. 

The  peculiar  interest  in  the  affection,  aside  from  the  importance 
of  a  proper  diagnosis,  lies  in  the  fact  that  the  further  organiza- 
tion of  the  effusetl  blood  may  cause  sMiiptoms  and  changes  about 
the  joint  that  may  be  mistaken  for  those  of  tuberculous  disease. 
There  may  be,  for  example,  persistent  swelling,  thickening  of 
the  tissues,  limitation  of  motion,  and  deformity  combined  mth 
more  or  less  weakness  and  discomfort.  These  symptoms  are 
explained  by  the  irritation  of  the  effused  blood  and  by  its  further 
absorption  and  organization,  which  necessitates  the  formation 
and  growth  of  new  bloodvessels;  practically,  a  granulation  tissue 
is  formed  that  erodes  the  cartilage  upon  which  the  fibrinous 
deposits  rest.  These  secondary  changes  resemble  the  early  stage 
of  osteoarthritis. 

Treatment. — The  local  treatment  is  rest  and  protection  com- 
buied  ^^^th  stimulating  applications  to  hasten  the  absorption  of 
the  effused  blood.  Several  deaths  have  been  reported  from  hemor- 
rhage after  operative  intervention  in  cases  in  which  the  affection 
had  been  mistaken  for  tuberculous  disease. 


Hemarthrosis. 

Hemorrhage  into  a  joint  may  occur  in  normal  individuals,  and 
its  presence  is  not  always  indicated  by  superficial  discoloration. 
The  swelling  is  more  resistant  than  is  the  ordinary  effusion,  and 
it  is  far  more  persistent.  This  suggests  the  advisability  of  inci- 
sion and  removal  of  the  blood  clots  in  certain  instances  in  order 
to  relieve  the  joint  of  burden  of  their  organization  and  absorption. 

Scorbutus— Scurvy. 

Tliis  affection  is  sometimes  attended  witli  hemorrhage  into  and 
about  the  joints.  It  will  be  considered  in  connection  with  in- 
fantile rhachitis. 

Charcot's   Disease. 

Charcot's  disease  is  a  form  of  destructive  artliritis  which  is 
secondary  to  locomotor  ataxia. 


NON-TUBERCULOUS  DISEASES  OE  THE  JOINTS        291 

Pathology. — It  resembles  somewhat  in  its  pathology  osteo- 
arthritis. The  cartilage  degenerates,  and,  together  with  the 
underlying  bone,  is  worn  away  by  the  movements  of  the  hml). 
Accompanying  the  destructive  process  there  is  an  exaggerated 
and  irregular  formation  of  cartilage  and  bone  about  the  periphery 
of  the  joint.  The  synovial  membrane  is  hypertrophied,  and  may 
be  covered  in  places  with  calcareous  plates;  the  contents  of  the 
joint  is  usually  increased  in  quantity. 

The  joint  disease  usually  appears  early  in  the  course  of  loco- 
motor ataxia,  often  before  its  existence  is  suspected,  and  it  is 
sometimes  caused  directly  by  injury. 


Fic.    192 


Charcot's  disease  of  the  knee-jjint. 

Charcot's  disease  is  said  to  affect  about  5  per  cent,  of  the  ataxic 
patients;  it  is  more  common  in  the  lower  extremity,  and  one  or 
more  joints  may  be  involved.  In  the  cases  tabulated  by  Flatow 
the  distribution  was  as  follows: 

Knee 60  ;  in  13  cases  both  knees. 

Foot 30 ;    "     9     "         "     feet. 

Hip 38;    "     9     "         "     hips. 

Shoulder 27  ;    "     6     "  "     shoulders.' 

Chipault^  notes  the  distribution  in  217  cases,  as  follows: 

1  Deutsche  Chir.,  1900,  vol.  1.  p.  28.  -'  Le  Dentu  et  Dcibet,  Traitd  de  Chir. 


292  ORTHOPEDIC  SURGERY 

Knee 120 

Hip 57 

Foot ....       40 

Fifteen  cases  of  Charcot's  disease  involving  the  spine  have 
been  reported.^ 

Symptoms. — The  s^Tnptoms  are  the  swelHng  due  to  the  effu- 
sion, laxity  of  the  ligaments,  and  deformity.  There  is  but  little 
pain,  and  the  patient's  chief  complaint  is  of  the  weakness 
and  distortion  of  the  limb.  In  certain  cases  the  progress  of  the 
affection  is  very  rapid,  and  the  destruction  of  bone  may  be  so  exten- 
sive that  there  is  an  actual  luxation  at  the  affected  joint. 

Diagnosis. — If  the  patient  is  known  to  have  locomotor  ataxia 
the  diagnosis  will  be  e\ddent,  and  in  any  event  the  peculiar  "en- 
largement, and  thickening  of  the  tissues,  together  with  the  exces- 
sive laxity  of  the  ligaments,  characteristic  of  this  affection,  which 
has  been  called  a  caricature  of  osteoarthritis,  should  call  attention 
to  the  disease  of  the  spinal  cord.  Of  this  the  diagnostic  symptoms 
are  absence  of  tendon-jerks  in  the  lower  extremities  combined 
with  disorders  of  sensation  and  lessened  muscular  tone,  and 
absence  of  reaction  of  the  pupils  to  light. 

Treatment. — The  treatment  of  the  local  disease  is  efficient 
support  to  prevent  progressive  distortion.  Excision  of  the  knee 
has  been  performed,  but  in  many  cases  the  bones  have  failed  to 
unite,  and  on  this  account  the  operation  is  contraindicated. 

Disease  of  joints  secondary  to  other  forms  of  disease  of  the  ner- 
vous system  may  occur.  It  is  most  common  as  a  complication 
of  syringomyelia,  19  cases  of  which  has  been  investigated  by  Bor- 
chard/  in  whicli,  in  contrast  to  locomotor  ataxia,  the  joints  of 
the  upper  extremity  are  far  more  often  involved  than  of  the  lower. 
The  symptoms  of  this  affection  are  loss  of  sensation  to  pain  and 
temperature,  disturbance  of  nutrition  and  muscular  atrophy. 

In  Schlesinger's  cases  the  distribution  was  as  follows:'' 


Shoulder 29 

Elbow 24 

Wrist 18 

Hip 4 

Knee 7 

Foot 7 

Other  joints 8 


'  Abadie.     Noiiv.  Toon,  de  la  Sali)i''trif-re,  '1'.  xiii.,  1900.     Cornell.    Johns  Hopkins  Hosp. 
Bull.,  October,  1902. 

-  DeutKchn  Zeit.  f.  Chir.,  lid.  Ixxii.,  1904. 

•'  Die    Syririgornyelie,  Wicu,  iHOr).  ,., 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        293 

In  all  forms  of  joint  disease  secondary  to  disease  of  the  ner\^ous 
system  the  influence  of  injury  on  the  ill-nourished  or  ill-protected 
part  is  recognized  in  the  causation  and  in  the  progress  of  the 
disease.     This  indicates  the  principles  of  local  treatment. 

Anchylosis. 

Anchylosis  iju plies  fixation  in  an  attitude  of  deformity,  and 
thejerm  should  be  restricted  to  practical  fixation  caused  by  tissue 
changes  within  or  without  a  joint,  but  it  is  often  incorrectly  applied 
to  limitation  of  motion,  such  as  may  be  caused,  for  example,  by 
muscular  spasm. 

Etiology  and  Pathology.— Anchylosis  may  be  the  result  of 
actual  union  of  two  bones  whose  cartilages  have  been  destroyed, 
a  synostosis.  This  is  sometimes  called  true,  as  distinguished 
from  false  or  fibrous  anchylosis. 

It  may  be  caused  by  adhesions  between  the  folds  of  synovial 
membrane,  by  adhesions  and  contractions  of  the  capsular  and 
other  ligaments,  by  adhesions  between  the  tendons  and  their 
sheaths,  by  the  general  adhesions  and  contractions  caused  by 
burrowing  abscesses,  and  by  the  retraction  and  structural  shorten- 
ing of  muscles  when  the  deformity  has  persisted  for  a  sufficient 
time.  It  may  be  caused,  also,  by  fractures  or  dislocations  or  by 
marginal  exostoses. 

Anchylosis  is  usually  secondary  to  an  inflammatory  affection 
of  the  joint  during  which  the  adhesions  have  formed  within  and 
without  the  capsule,  and  if  deformity  has  been  allowed  to  persist 
the  muscles  are  atrophied  and  structurally  shortened  on  the  con- 
tracted side. 

Prevention  and  Treatment.— The  danger  of  anchylosis  may 
be  lessened  by  the  proper  treatment  of  the  disease  of  which  it 
is  a  result.  In  tuberculous  disease,  for  example,  motion  may  be 
preserved  in  many  instances  by  efficient  protection,  by  which  the 
area  of  the  disease  is  restricted  and  its  destructive  effects  checked. 
In  this  class  of  cases  the  joint  should  be  fixed  during  the  pro- 
gressive stage  of  the  disease,  in  the  attitude  in  which  anchylosis, 
if  it  be  unavoidable  will  least  inconvenience  the  patient,  and,  if 
possible,  efficient  traction  should  be  employed  with  the  aim  of 
separating  the  surfaces   of  the   adjoining  bones. 

Formerly  it  was  believed  that  prolonged  fixation  of  a  diseased 
joint  would  of  itself  induce  anchylosis,  but  now  that  it  is  known 
that  final  limitation  of  motion  is  dependent  upon  the  severity  and 


294 


ORTHOPEDIC  SVEGEBY 


the  duration  of  the  disease,  prolonged  rest  is  beheved  to  be  the 
most  efficient  means  of  assurmg  motion. 

In  tuberculous  cases,  when  the  disease  is  cured,  functional  use 
will  ordinarily  restore  all  the  motion  of  which  the  part  is  capable. 
In  other  mflammatory  affections  of  the  joint  which  are  usually  of 
infectious  origin  the  violence  of  the  inital  process  may  be  restrained 
bv  the  local  application  of  cold  or  heat,  or  by  the  removal  of  the 


Fig.   193 


i^HVy^:^^ 

|^H| 

"^^^1 

^1 

fc^^ 

^ 

I  ■ 

^^^^^^^^ri- 

La 

A  useful  form  of  brace  for  weak  knee,  in  whioli  tlie  range  of  motion  is  regulated  by 
means  of  an  adjustable  wheel.     (Shaffer.) 


contents  of  the  joints  if  the  infection  is  severe.  In  all  cases  the 
joint  should  be  properly  supported  in  order  to  relieve  pain  and 
to  prevent   deformity. 

Passive  Motion.  VVIkmi  tlic  acute  symptoms  have  subsided 
the  abs(jrption  of  the  plastic  material  may  be  hastened  by  mass- 
age, the  iiot-air  l)ath,  and   the  hkc,  and   by  carefully  regulated 


Fig.   194 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINTS        295 

passive  and  active  motion. ',  Passive  congestion  after  the  method 
of  Bier  may  be  of^^service  in  certain  cases.   It  is  highly  recommended 
by  Blecher.^     In  the  final  stage,  when  there  is  no  longer  evidence 
of  active  disease,  passive  movements  under  anaesthesia  may  be 
of  service  in  breaking  adhesions,  espe- 
cially if  these  are  without  the  joint. 
Passive  movements  that   cause  per- 
sistent discomfort  or  pain,  which  are 
often  employed  in  the  treatment  of 
stiff  joints,  even  when  the  disease  Ls 
active,  are  absolutely  contraindicated. 
If,  however,    the    limb    during    the 
course  of    the    disease    has   become 
deformed,  it  should  be   restored   to 
its  proper  position  as  soon  as  possible, 
even  though  force  is  required.     This 
treatment   is   indicated   in    order   to 
prevent  secondary  retraction  of   the 
muscles  and  fasciae. 

Forcible  Correction. — The  class  of 
cases  in  which  the  limb  has  become 
fixed  in  deformity  is  the  most  favor- 
able one  in  which  to  perform  the  so- 
called  brisement  force,  because  the 
rectification  of  deformity  Ls  always 
indicated,  and  in  accomplishing  this 
there  is  always  the  prospect  of  regain- 
ing a  certain  degree  of  motion.  If, 
however,  there  is  no  deformity  the 
advisability  of  forced  movement  will 
depend  on  the  character  of  the  pre- 
ceding disease  as  well  as  upon  the 
condition  of  the  joint.  It  is  rarely 
advisable   to    disturb   a  tuberculous 

joint    except    for    the    purpose    of    cor-         Anchylosis  at  the  hii),  showing  masses 
,    p  .  ,  .,     of  new  bone.     (From  the  Museum  of  the 

reCtmg    deiormity    at    least    not    until    CoUege  of  Physicians  ami  Surgeons.) 

long  after  the  cure  of  the  disease ;  but 

if  the  anchylosis  has  followed  infectious  arthritis  of  a  mild  form, 
or  monarticular  "rheumatism,"  forcible  manipulation  may  be 
attempted.  If  under  gentle  manipulation  the  adhesions  give  way 
suddenly,  allowing  free  motion,  the  prognosis  is  good;  but  if  there 


'  Deutsche  Zeit.-!.  f.  Chir.,  Bd.  Ix.  p.  250. 


296  OR THOPEDIG  S  UR  GERI 

is  a  peculiar,  elastic,  continuous  resistance,  as  when  there  are 
extensive  adhesions  withm  the  jomt,  there  is  little  likelihood  of 
attaming  motion  by  this  means.  If  but  slight  force  has  been 
exerted  there  is  usually  but  little  reaction,  and  massage  and  passive 
motion  may  be  employed  at  once ;  but  in  other  mstances  the  mani- 
pulation is  followed  by  swelling  and  pain,  and  until  these  symp- 
toms have  subsided  fixation  may  be  indicated.  It  may  '.be  men- 
tioned that  anchylosis  following  disease  is  usually  accompanied  by 
marked  atrophy  of  the  bones,  and  fracture  may  occur  during 
forcible  correction.  In  cases  of  this  character  the  rare  complica- 
tion of  fat  embolism  is  sometimes  encountered. 

Afterward,  passive  movements  within  the  range  that  is  practi- 
cally painless  may  be  carried  out  manually,  or  by  means  of  one  of 
the  so-called  pendulum  machines,  by  which  the  joint  is  moved 
back  and  forth  at  frequent  intervals  until  the  part  is  fatigued. 
Functional  use,  when  the  joint  is  protected  by  apparatus  that 
limits  the  range  of  motion  to  the  painless  area,  is  also  of  service. 

The  a^-ray  may  be  of  value  in  demonstrating  the  condition  of 
the  joint  and  the  degree  of  atrophy  of  the  bones,  but  the  history, 
which  should  indicate  the  character  of  the  disease,  and  the  physical 
examination  are  far  more  reliable  from  the  standpoint  of  prognosis. 
In  some  instances  operative  exploration  of  the  joint  may  be  indi- 
cated. This  permits  the  removal  of  exostoses  or  displaced  frag- 
ments of  bone  after  fracture  that  may  limit  motion  mechanically. 
Recently  the  attempt  has  been  made  to  prevent  reunion  of  the 
surfaces  of  the  adjoining  bones  by  the  insertion  of  thin  plates 
of  magnesium  or  other  absorbable  substance,  as  one  prevents 
union  in  smaller  joints  by  interposing  muscular  or  other  tissue. 
As  yet  the  method  is  in  the  experimental  stage. 

Murphy,^  of  Chicago,  has  reported  a  number  of  cases  treated  by 
interposition  of  flaps  of  fibrofatty  tissue.  At  the  knee,  for  example, 
the  joint  is  exposed  by  raising  a  broad  anterior  flap  of  skin.  The 
capsule  is  then  removed,  only  the  lateral  ligaments  being  preserved. 
The  bones  are  then  separated  completely,  obstructions  to  move- 
ment cut  away,  and  broad  flaps  of  fibromuscular  tissue  from 
the  lateral  aspect  of  the  muscles  on  one  or  both  sides  of  the  joint 
are  turned  down  and  are  inserted  between  the  bones  and  beneath 
the  patella  if  this  is  adherent.  The  skin  is  then  united.  Later 
massage  and  passive  motion  are  cmploy(xl. 

This  operation  may  be  of  service  in  ('{Ttain  carefully  selected  cases 
particularly  those   in   which  the  destruction  of  tissue  has   been 

'  Journal  of  the  American  Medical  Association,  May,  1905. 


NON-TUBERCULOUS  DISEASES  OF  THE  JOINIS        297 

slight  and  in  which  the  patella  is  free.  As  a  rule,  however,  at 
least  in  the  working  class,  an  anchylosed  joint  of  the  lower  ex- 
tremity is  far  more  serviceable  than  one  in  which  a  few  degrees 
of  motion  persist.  For  whenever  the  joint  is  strained  by  an 
unguarded  movement  the  patient  suffers  discomfort,  and  motion 
uncontrolled  by  the  muscles,  as  in  the  cases  in  which  the  patella 
is  fixed,  is  worse  than  useless. 

At  the  ankle-joint  removal  of  the  astragalus  will  often  restore 
motion,  and  in  the  upper  extremity  excision  of  the  joint  at  the 
shoulder  or  elbow  is  equally  efficacious. 


CHAPTER   VII. 

"  TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 

Synon3mis. — Hip  disease,  morbus  coxse. 

Hip  disease  is  a  chronic  destructive  disease  that  results  in  loss 
of  function  and  deformity.  At  one  time  a  nimiber  of  pathological 
processes  and  even  simple  deformity  (coxa  vara)  were  included 
under  the  title,  but  it  is  now  limited  to  tuberculous  disease. 

Fig.   195 


Section  of  the  hip-joint  at  the  age  of  eight  years,  showing  the  epiphyses  and  the  relation 
of  the  capsule.  (Schuchardt.)  At  birth  the  entire  upper  extremity  of  the  femur  is  carti- 
laginous. According  to  Jacinsky,  o.ssification  begins  in  the  head  of  the  femur  at  about  the 
tenth  month;  in  the  trochanter  major  at  from  the  fourth  to  the  eighth  year;  in  the  tro- 
chanter minor  at  the  eleventh  year.  Ossification  is  complete  at  all  points  at  about  the 
eighteenth  year.  Kange  of  motion  at  the  hip-joint.  Extension  to  20  degrees  beyond  the 
horizontal;  flexion  to  70  degrees;  total  140  degrees.  Abduction,  adduction,  and  rotation 
are  most  free  when  the  limb  is  flexed  60  degrees  At  this  point  the  range  of  adduction  is 
55  degrees,  of  adduction  35  degrees;  total  90  degrees.  Outward  rotation  40  degrees,  in- 
ward rotation  20  degrees;  total  60  degrees.  If  the  limb  is  completely  extended  the  range 
of  abduction  is  about  40  degrees;  adduction,  15  degrees.' 

Pathology. — Tuberculous  disease  of  the  hip-joint  usually 
begins  in  several  minute  foci  in  the  neigliborhood  of  the  epi- 
physeal cartilage  of  the  head  of  the  femur.  Here  the  circulation 
is  most  active,  and  here  the  newly-formed  bone  is  least  resistant. 
Thus  the  bacilli,  carried  by  the  blood,  are  more  often  deposited 


1  K.  <iu  IJois-Uaymond,  Berlin,  1903. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


299 


at  this  point,  where,  under  favoring  conditions,  tlie  disease  is 
established.  These  foci  coalesce  and  an  area  of  infected  granu- 
lations replaces  the  normal  structure.  If  the  local  resistance  is 
sufficient  the  disease  may  be  confined  to  the  interior  of  the  bone, 
but  in  most  instances  it  gradually  forces  its  way  into  the  joint 
and  tne  granulation  tissue,  spreading  under  and  over  the  carti- 
lage, destroys  it  in  its  prcjgress.  The  lining  memln-ane  of  the 
joint  becomes  involved  in  the 

disease,  and,  finally,  the  ad-  ^''"-  ^^° 

joining  surface  of  the  acetabu- 
lum as  w^ell.  In  a  certain 
indeterminate  number  of  cases 
the  tuberculous  process  begins 
about  the  epiphyseal  junc- 
tions of  the  acetabulum,  and 
primary  disease  of  the  synovial 
membrane  may  occur,  although 
this  is  certainly  uncommon  in 
childhood. 

From  the  clinical  stand- 
point, primary  disease  of  the 
acetabulum  may  be  inferred 
when  the  patient  is  particu- 
larly susceptible  to  movements 
of  the  trunk,  or  when  lateral 
pressure  on  the  pelvis  causes 
pain;  or  when  a  Roentgen 
picture  shows  greater  erosion 
of  the  acetabulum  than  of  the 
head  of  the  femur  (Fig.  209). 
There  are  other  cases  in  which 
the  symptoms  of  the  disease 
are  slight  and  in  which  swell- 
ing about  the  joint  is  noticeable;  in  such  cases  it  is  probable 
that  disease  of  the  synovial  membrane  is  present  without  marked 
involvement  of  the  head  of  the  femur  or  of  the  acetabulum. 

In  the  common  or  osteal  form  of  disease,  while  the  tuber- 
culous process  is  still  confined  within  tl.e  head  of  th.e  femur, 
the  joint  shows  e^^(lences  of  sympathetic  irritation;  tl.e  synovial 
membrane  is  congested,  and  th.e  fluid  within  the  joint  is  increased 
in  (juantity.  These  changes  become  more  marked  as  tlif  disease 
progresses,  the  lining  membrane  becomes  thickened  and  granular, 


Wandering  of  the  acetabulum"  in  hip  disease. 
(Krause.) 


300 


ORTHOPEDIC  SURGERY 


and  adhesions  between  its  folds  lessen  the  capacity  of  the  joint.  An 
amount  of  tuberculous  fluid,  large  enough  to  be  recognized  as  an 
"abscess,"  is  present  in  about  half  the  cases  at  some  time  during 
the  course  of  the  disease.  This  fluid  usually  finds  an  exit  from 
tlie  capsule  into  the  tissues  of  the  thigh,  but  occasionally  it  may 
pass  through  the  acetabulum  into  the  pelvis.  In  rare  instances 
the  disease  may  not  enter  the  joint,  but  may  find  an  opening 
in  the  neck  outside  the  capsule.  In  such  cases  the  joint  is,  in 
most  instances,  finally  involved    unless  the  disease  is  removed 

Fig.  197 


/I 

^V^^'^'^^^^H 

•k- 

1 

|r 

w% 

-jm 

'**'*"'**^ 

9w     'm.       '^ 

KF       w  -  -^ 

Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of  the  acetabulum.     Formation 
of  new  bone  (osteophytes)  about  the  acetabulum. 

by  surgical  means.  There  are  cases,  also,  in  whicli  the  disease, 
confined  within  the  head  of  the  bone,  so  weakens  it  that  it 
becomes  distorted  to  a  marked  degree  without  destruction  of  the 
cartilage. 

If  the  disease  involves  the  neck  of  tfie  bone  it  may  sink  down- 
ward, a  form  of  coxa  vara;  or  the  head  of  the  bone  may  be 
separated  at  the  epiphyseal  junction,  with  consequent  upward 
displacement  of  the  shaft. 

In  by  far  the  larger  number  of  cases  the  joint  is  perforated 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


301 


and  the  head  of  the  femur  and  the  acetabulum  are  eroded  to  a 
greater  or  less  degree.  In  such  instances  the  destructive  effects 
of  the  disease  are  increased  by  the  pressure  and  friction  of  the 
softened  bones  on  one  another,  aggravated  by  the  spasm  of  the 
surrounding  muscles.  'J'hus  at  the  upper  margin  of  the  acetabu- 
lum and  the  inner  and  upper  surface  of  the  femur  there  is  greater 
loss  of  substance  than  elsewhere  (Fig.  197). 

The  appearances  in  advanced  cases  of  this  type,  as  seen  at 
operation  or  autopsy,  may  be  summarized  somewhat  as  follows: 
The  head  of  the  femur  is  deeply  eroded,  its  cartilaginous  cover- 


FiG.   198 


■■ 

■ 

^^P^'  '^^^^^^^^MMIH 

1 

r 

Wa 

4 

Erosion  of  the  head  of  the  femur  and  of  the  upper  margin  of  the  acetabulum. 
A,  anterior  superior  spine.     B,  anterior  inferior  spine. 

ing  has  practically  disappeared,  or  is  in  part  still  adherent  in 
necrotic  shreds.  It  lies  in  seropurnlent  fluid,  embedded  in  the 
gelatinous  necrotic  granulations  that  line  the  capsule  and  partly 
fill  the  acetabulum. 

In  certain  instances  the  disease  may  extend  to  the  adjoining 
surface  of  the  pelvis,  or  the  acetabulum  may  be  perforated  (Fig. 
199),  or  the  medullary  cavity  of  the  femur  may  be  implicated. 
Occasionally  the  disease  may  be  from  the  first  of  an  acute  de- 
structive type,  whose  course  is  but  little  influenced  by  treatment, 


302 


ORTHOPEDIC  SURGERY 


but  in  the  majority  of  cases  the  progress  of  the  disease  and  its 
destructive  effects  may  be  greatly  modified  by  efficient  protection 
of  the  joint. 

In  the  natural  cure  of  the  disease  the  focus  within  the  bone,  if 
it  be  smallj  may  be  absorbed  and  replaced  by  scar-like  tissue;  or 
the  prodiicts  of  the  disease  may  be  separated  from  the  healthy 
parts,  and  discharged  by  abscess  formation.  In  other  instances 
a  part  in  which  the  disease  is  still  active  may  be  enclosed  within 
the  newly-formed  tissue.  Here  the  process  may  remain  quiescent 
or  it  may  cause  relapse,  many  years  after  the  apparent  cure. 
Or  portions  of  necrosed  bone,  enclosed  within  the  capsule,  may 
prolong  suppuration  aftar  the  tuberculous  disease  has  ceased  to 
progress. 

Etiology. — The  etiology  of  tuberculous  disease  is  discussed  in 
Chapter  V. 

Relative  Frequency. — Tuberculous  disease  of  the  hip-joint  is  the 
most  common  and  the  most  important  of  the  affections  of  the 
joints,  ranking  second  to  Pott's  disease.  In  a  total  of  7845  cases 
of  tuberculous  disease  treated  in  the  out-patient  department 
of  the  Hospital  for  Ruptured  and  Crippled  during  a  period  of 
fifteen  years  3203  were  Pott's  disease,  2230  were  hip  disease, 
while  the  remaining  2412  cases  included  all  the  other  joints. 

Age. — Hip  disease  is  essentially  a  disease  of  early  childhood, 
although  no  age  is  exempt.  In  a  series  of  1000  consecutive  cases 
of  hip  disease  tabulated  for  me  by  Ashley,  formerly  an  assistant 
in  the  department,  88.1  per  cent,  of  the  patients  were  in  the  first 
decade  of  life,  and  45.6  per  cent,  of  these  were  from  three  to  five 
years  of  age,  inclusive. 

Age  at  Incipiency. 


Less  than  lyear 

9 

Between  16  and  17  years  . 

11 

Between   1  and 

2  years  . 

39 

17  ' 

18   •' 

4 

2  " 

3  " 

107 

18  ' 

19  "  '  . 

5 

3  " 

4   "   . 

155 

19  • 

20  " 

0 

4  " 

5   "   . 

158 

20  ' 

21   " 

3 

5  " 

G   "   . 

139 

21  ' 

22   " 

3 

6  " 

7  "   . 

90 

22  ' 

23  " 

1 

7  '■' 

8  "   . 

51 

23  ' 

24  " 

2 

8  " 

9  "   . 

51 

24  ' 

25   " 

3 

9  " 

10  "   . 

40 

25  ' 

26   ' ' 

1 

10  " 

11   " 

33 

26  ' 

27   " 

1 

11  " 

12   "   . 

19 

27  ' 

28   " 

1 

12  " 

13   "   . 

18 

28  ' 

29   " 

1 

13  " 

14   "   . 

23 

30  ' 

33  " 

4 

14  " 

15  "   . 

7 

33  "  36   " 

1 

15  " 

16  "   . 

8 

Age  not  stated  . 

12 

1000 


Sex. — Sex     exercises    liut    little     influence    in     predisposition, 
although  the  disease  is  slightly  more  common  among  males  than 


TUBERCULO  US  D  TSEA  SE  OF  THE  HIP-JOINT 


303 


among  females.     In  the   1000  cases  referred   to,   553   (55.3  per 
cent.)  were  in  males,  447  were  in  females. 

In  3307  cases  treated  at  the  same  institution,  53  per  cent,  were  in 
males. 

Side  Affected. — In  disease  of  this  as  of  other  joints  the  right  is 
somewhat  more  often  affected  than  the  left.  In  the  1000  cases 
506  were  on  the  right  side,  483  were  on  the  left,  and  in  11  cases 
both  joints  were  involved.  In  a  larger  number  of  cases  treated 
in  the  department  53  per  cent,  were  of  the  right  joint. 

Symptoms. — Tuberculous  disease  of  the  hip-joint  is  a  chronic, 
insidious  affection  characterized  by  occasional  exacerbations  of 
more  acute  symptoms  that 

may  be  induced  by  over-  ^"^-  ^^^ 

strain  or  injury,  by  a  more 
rapid  advance  of  the  de- 
structive process,  or  by 
infection  with  pyogenic 
germs.  In  the  early  stage 
of  the  disease  the  joint  is 
simply  sensitive,  and  the 
symptoms  vary  v^dth  the 
activity  of  the  disease, 
which  may  increase  the 
tension  wathin  the  bone, 
the  susceptibility  of  the 
patient,  and  the  strain  to 
which  the  weakened  part 
is  subjected.  This  sensi- 
tiveness is  first  indicated 
by  the  involuntary  adapta- 
tion of  the  body  to   the 

weakness   of  the   affected    joint,  or,  as   popularly  expressed,  the 
patient  favors  the  leg. 

The  important  symptoms  of  disease  of  the  hip-joint,  in  the 
sense  of  attracting  attention  to  the  affection,  are  pain  and  limp. 
Of  the  two,  pain  is  much  the  less  significant.  Hip  tlisease  is  by 
no  means  a  painful  disease,  and  although  patients  are  often 
brought  for  treatment  because  of  pain,  it  is  usually  apparent, 
on  examination,  that  the  disease  must  have  existed  long  before  the 
acute  exacerbation  called  attention  to  its  serious  character.  Even 
in  cases  in  which  the  disease  is  far  advanced,  one  may  be  assured 
that  the  patient  has  never  complained  of  pain. 


Erosion  of  the  head  of  the'femur  and  destruction 
of  the  acetabulum. 


304  ORTHOPEDIC  SURGERY 

Pain. — The  characteristic  pain  of  hip  disease  is  "pain  in  the 
knee,"  referred,  as  is  the  pain  of  Pott's  disease,  to  the  more  im- 
portant distribution  of  the  nerves,  whose  filaments  are  irritated 
by  the  local  process.  The  hip-joint  is  supplied  by  the  anterior 
criu-al,  the  sciatic,  and  the  obturator  nerves,  but  the  pain  is  more 
often  referred  to  the  distribution  of  the  last,  thus  to  the  inner 
side  of  the  knee.  Pain  so  persistently  referred  to  the  knee  is 
misleading,  and  patients  are  often  treated  for  obscm'e  affections  of 
this  joint  long  after  an  examination  of  the  hip  would  have  made 
the  diagnosis  e^'ident. 

The  pain  of  hip  disease  is  induced  by  sudden  or  unguarded 
movements,  or  by  injury;  tlierefore,  in  many  instances,  it  is  rather 
an  occasional  than  a  constant  symptom.  Persistent  pain  almost 
always  indicates  the  increased  tension  either  within  the  bone  or 
within  the  joint  that  accompanies  abscess  formation. 

Night  Cry. — Pain  at  night  is  of  importance,  as  it  more 
often  attracts  attention  than  the  occasional  complaint  of  discom- 
fort during  the  day.  It  is  a  common  symptom  when  the  disease 
is  at  all  acute  in  character,  and  it  is  often  present  when  pain, 
during  the  period  of  activity,  is  apparently  absent.  It  may  be 
inferred,  as  an  explanation  of  this  symptom,  that  the  joint 
gradually  becomes  more  sensitive  under  the  strain  of  use  during 
the  day,  and  that  the  relaxation  of  the  voluntary  and  involuntary 
protection  of  the  muscles  allows  sudden  movements  that  excite 
spasmodic  muscular  contractions,  which  force  the  sensitive  parts 
against  one  another.  This  causes  a  sharp  cry.  If  the  disease 
is  acute,  the  child  is  usually  awakened  and  is  found  holding  the 
thigh  with  the  hands  or  pressing  upon  the  limb  with  the  other 
foot,  the  e\^dence  of  pain  being  unmistakable.  In  the  less  sen- 
sitive conditions  the  patient  does  not  wake  after  crying  out,  but 
simply  moans  or  is  restless  for  a  time.  If  awakened  it  makes  no 
complaint  of  pain  and  the  cry  is  supposed  to  be  caused  by  a  "bad 
dream."  This  cry  may  be  repeated  several  times,  more  often  in 
the  early  part  of  the  night. 

Direct  local  pain  and  sensitiveness  to  pressure  are  unusual 
unless  the  disease  is  acute  in  character,  or  unless  the  tissues  over- 
lying the  joint  are  implicated,  as  in  abscess  formation. 

Limp. — The  limp  is  the  most  important  of  what  may  be  classed 
as  the  preliminary  signs  of  the  disease.  A  limp  is  a  change  in 
the  rhythm  of  the  gait,  a  long  step  alternating  with  a  shorter 
step.  It  is  evident  that  any  interference  with  the  function  of 
the  lirn}>  will  cause  this  irregularity  whiqh  can  be  concealed  ov 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  305 

diminished  only  by  accommodating  the  normal  member  to  its 
disabled  fellow.  Thus  an  inequality  in  length  or  a  limitation  of 
motion  in  the  joint  or  distortion,  or  weakness  or  pain,  may  cause 
an  arrhythmical  gait.  Several  of  these  factors  may  be  combined 
in  the  causation  of  the  final  disability  of  hip  disease,  but  in  the 
beginning,  the  limp  is  due  rather  to  sensitiveness  than  to  any 
marked  restriction  of  function.  Thus  the  patient  favors  the 
joint  by  resting  on  the  limb  for  a  shorter  time  than  on  its  fellow, 
and  by  bearing  more  weight  upon  the  front  of  the  foot  than  upon 
the  heel.  If  the  joint  is  very  sensitive,  the  patient  may  bear 
practically  all  the  weight  upon  the  front  of  the  foot,  slight  plantar 
flexion  at  the  ankle  being  combined  with  slight  flexion  at  the 
knee  and  hip;  thus  the  jar  of  direct  impact  of  the  heel  upon  an 
extended  leg  is  avoided. 

The  limp  is  practically  a  constant  symptom  of  hip  disease; 
it  is  as  a  rule  more  noticeable  in  the  morning  or  on  changing  from 
an  attitude  of  rest  than  during  activity.  The  limp  may  be  inter- 
mittent even,  although  it  is  probable  that  in  most  instances  some 
change  from  the  normal  gait  might  be  detected  by  a  practised  eye . 

The  other  symptoms  of  disease  of  the  hip-joint  are  more  prop- 
erly physical  signs  that  become  evident  on  examination.  These 
are:  stiffness,  distortion,  change  of  contour,  and  atrophy. 

Stiffness,  due  to  reflex  muscular  spasm,  is  by  far  the  most 
important  sign  of  the  disease.  It  is  the  instinctive  expression  of 
the  inability  of  the  joint  to  perform  its  full  function  and  espe- 
cially to  allow  the  full  range  of  motion  which  increases  the  strain 
upon  the  joint.  It  is  the  first  and  the  last  sign  of  disease;  it  prob- 
ably precedes  the  limp,  and  it  remains  long  after  pain  has  ceased 
to  be  a  s}Tnptom,  and  until  repair  is  complete. 

Reflex  muscular  spasm  limits  motion  in  every  direction  to  a 
greater  or  less  degree.  iYt  an  early  stage  of  the  disease  the  motion, 
whether  voluntary  or  passive,  may  be  perfectly  free  throughout 
three-fourths  of  its  normal  range,  but  when  the  limit  allowed 
by  the  muscular  protection  is  reached  motion  is  checked  by  a 
peculiar  elastic  resistance.  If  an  attempt  is  made  to  force  the 
limb  beyond  the  limit  set  by  the  muscular  resistance  the  entire 
body  follows  the  movement.  The  contraction  of  the  surrounding 
muscles,  including  those  of  the  trunk  even,  may  be  appreciated 
by  the  eye  and  by  the  hand,  and  the  expression  of  the  patient's 
face  shows  discomfort  and  apprehension. 

The  degree  of  muscular  spasm  corresponds  to  the  sensitiveness 
of  the  joint  rather  than  to  the  area  of  the  destructive  disease. 

20 


306 


ORTHOPEDIC  SURGERY 


Thus  it  may  vary  from  day  to  day  and  eyen  from  hour  to  hour, 
and  in  the  acute  exacerbations  of  the  disease  motion  may  be  for  a 
time  so  absolutely  restricted  as  to  simulate  anchylosis. 

Reflex  muscular  spasm  is  an  infallible  sign  of  a  sensitive  joint; 
it  is,   of  course,  not  diagnostic  of  the  tuberculous  process,  but 


Fk:.   200 


Apparent  lengthening.     Fixed  abduction  of  45°.     When  the  anterior  superior  spines   are 
on  the  same  plane,  as  in  the  illustration,  the  deformity  is  evident.     (See  Fig.  201.) 

unless  it  is  the  direct  effect  of  injury  it  indicates  disease,  and 
if  this  disease  is  chronic  and  confined  to  a  single  joint  it  is,  in 
cliiidhood  at  least,  almost  always  tuberculous  in  character.  In 
the  early  stage  of  hip  disea.se  the  restriction  of  motion  is  caused 
almost  entirely  by  reflex  muscuhir  s})asm,  as  is  shown  by  the  fact 
that  when  the  patient  is  ana*sthetized  the  range  of  motion  becomes 


TUBERCULOUS  DISEASE  OF  THE  IIIP-JOINT 


307 


practically  free.  As  the  destructive  process  progresses  motion 
is  still  further  restrained  by  adhesions  anrl  contractions  within 
and  without  the  joint. 

Distortion  of  the  Limb. — Persistent  reflex    muscular  spasm  is 
always  accompanied  by  a  certain  change  in  the  attitude  of  the 


Fig.  201 


Apparent  lengthening.  When  the  ah- 
ihicted  limb  is  brought  to  the  median  line 
the  pelvis  is  so  tilted  that  it  seems  longer. 
(See  Fig.  200.) 


Hight-angle  lle.xion  in  hip  disca.se  partly 
concealed  by  the  conii)ensatory  lordosis  and 
by  the  flexion  at  the  knee  and  ankle. 


limb,  sliglit  flexion  being  the  earliest  indication  of  distortion  here 
as  at  exevy  other  joint.  With  fle.xion  there  is  usually  abduction 
with  slight  outward  rotation  of  the  limb. 

Flexion,    Abduction,    and    Outward    Rotation.    Appar- 
ent Lengthening. — ^lliis  is  the  passive  attitude  or  the  attitude 


308 


OR THOPEDIC  S URGEB Y 


of  rest  in  the  normal  condition,  and  in  disease  it  shows  the  in- 
stinctive adaptation  of  the  Umb  to  a  sensitive  joint  which  is  still 
capable  of  a  certain  amount  of  Avork.  The  flexion  lessens  the 
direct  jar  and  the  abduction  throws  the  limb  aside,  as^it  were, 
from  the  active  attitude,  making  it  a  prop  and  adjunct  of  its 
fellow  instead '  of  an  active  aid  in  the  propulsion  of  the  body. 
This  attitude  is  not  voluntarily  assumed  by  the  patient;  it  is 
involuntary  and  persistent.  The  limb  is  apparently  lengthened, 
because  it  is  held  away  from  the  axis  of  the  body,  and  in  order 
to  bring  it  into  the  middle  line  and  parallel  to  its  fellow  the  pelvis 
must  be  tilted  dowTiward  on  the  diseased  side  and  upward  on 
the  other.  The  sound  limb  is  drawn  upward  and  the  affected 
limb  is  lowered  according  to  the  degree  of  abduction  (Fig.  201). 


Fig.  203 


The  degree  of  fixed  flexion  is  shown  when  the  lumbar  spine  is  held  in  contact  with  the  table 
by  flexing  the  other  thigh. 

If,  however,  the  anterior  superior  spines  of  the  pelvis  are  placed 
upon  the  same  plane,  the  distortion  becomes  evident  (Fig.  200). 
Thus  the  deformity  of  the  limb  is  concealed  or  compensated  by  a 
tilting  of  the  pelvis  which  twists  the  lumbar  spine  into  a  lateral 
convexity  toward  the  lower  side. 

In  the  same  manner  persistent  flexion  of  the  limb  is  concealed 
by  a  tilting  of  the  pelvis  forward,  and  by  an  increased  hollow- 
ness  or  lordosis  of  the  lumbar  region  (Fig.  202).  Normally,  in 
childhood  at  least,  the  lumbar  spine  and  the  popliteal  surface  of 
the  knee  should  touch  the  table  when  the  patient  lies  upon  the 
back;  but  if  the  thigh  is  fixed  in  flexion  the  lumbar  region  must 
be  arched  and  raised  from  the  table  when  the  leg  rests  upon  it. 
Thus,  in  orrler  to  make  the  flexion  apparent,  the  lumbar  spine 
must  be  forced  to  touch  the  table,  and  this  is  possible  only  when 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


309 


the  limb  is  raised  to  a  degree  corresponding  to  the  deformity 
(Fig.  203).  If  the  spine  were  rigid,  as  in  spondyKtis  deformans, 
this  compensation  would  be  impossible,  and  if  the  patient  were 


Fig.  204 

m.^\ 

V    ■ 

1 

Fig.  205 


Apparent  shortening.  The  adduction  of 
the  right  thigh  is  made  evident  by  the  invol- 
untary crossing  of  the  legs  when  the  anterior 
superior  spines  are  on  the  same  plane. 


Apparent  shortening  When  the  adducted 
limb  is  placed  in  the  line  of  the  body,  the 
pelvis  is  tilted  upward  on  the  adducted  side 
and  downward  on  the  other.  The  patient  has 
compensated  for  the  apparent  shortening  by 
flexing  the  knee  on  the  sound  side.  This 
does  not  appear  in  the  photograph. 


placed  upon  his  back  the  leg  could  not  be  brought  down  to  the 
table;  or  if  both  limbs  were  distorted,  as  is  sometimes  the  case 
when  both  hip-joints  are  diseased,  tlie  limbs  would  remain  widely 
separated  or  ci'ossed  over  one  anotlier,  according  to  the  character 
of  the  deformity. 


310  OB  TH  OPE  Die  SURGERY 

Flexion,  Adduction,  and  Inward  Rotation.  Apparent 
Shortening. — If  the  disease  is  of  a  more  acute  type,  and  if  loco- 
motion be  permitted,  the  attitude  usually  changes  to  one  of 
increased  flexion;  and  adduction  and  inward  rotation  replace 
abduction  and  outward  rotation.  This  attitude  is  an  indication 
that  the  joint  is  so  disabled  as  to  be  of  little  service,  thus  the  limb 
is  instinctively  drawn  into  a  more  protected  attitude,  where  it 
may  be  used  as  little  as  possible.  If  the  patient  is  confined  to 
the  bed,  or  does  not  walk,  as  in  hip  disease  in  infancy,  the  atti- 
tude of  abdu?tion  may  persist,  although  the  muscular  spasm  may 
be  intense.  Thus  it  would  appear  that  locomotion  has  a  distinct 
influence  on  the  character  of  the  distortion. 

Adduction  causes  apparent  or  practical  shortening;  for  in 
order  to  bring  the  adducted  limb  to  the  middle  line  of  the  body 
and  parallel  to  its  fellow,  the  pelvis  must  be  tilted  upward  on 
the  affected  side  and  downward  on  the  other,  the  lumbar  spine 
bending  with  the  convexity  toward  the  lower  side  (Figs.  205  and 
208).  If  the  level  of  the  pelvis  be  restored,  the  adducted  limb 
will  be  crossed  over  its  fellovi^,  and  the  deformity  is  made  evident 
(Fig.  204j.  ; 

As  has  been  stated,  the  attitude  of  flexion,  adduction,  and 
inward  rotation,  if  it  appears  early  in  the  disease,  is  usually  an 
indication  of  acute  and  disabling  pain  and  of  corresponding  in- 
tensity of  muscular  spasm.  But  in  most  instances  it  is  associated 
with  the  later  and  tlestructive  stage  of  the  disease,'  and  it  by  no 
means  indicates  that  the  preceding  symptoms  have  been  more 
than  ordinarily  acute.  In  fact,  it  is  the  attitude  characteristic 
of  a  so-called  "natural  cure"  (Fig.  206)  when  mechanical  treat- 
ment has  not  been  employed.  It  more  often  accompanies  the 
hiter  course  of  the  <lisease,  because  its  causes  are  in  great  degree 
mechanical. 

This  is  illustrated  by  Koenig's  statistics  of  499  cases  of  hip 
disease. 

In  207  cases  the  limb  was  abducted,  and  in  31  per  cent,  of 
these  there  was  actual  shortening. 

In  232  cases  adchiction  was  present,  and  in  70  ])er  cent,  the 
limb  was  shorter  than  its  fellow.^ 

The  mechanics  of  the  distortion  as  indicative  of  the  destructive 
stage  of  the  disease  will  be  made  clearer  if  it  be  compared  to  the 
deformity  caused  by  dorsal  dislocation  of  the  hip.  In  this  dis- 
placeinent  the  femur,  forced  upward  and  backward  upon  the  pelvis, 

'  Koenig,  Das  Uoeftgelenk,  Berlin,  lOOiJ. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


311 


is  fixed  in  an  attitude  of  extreme  flexion,  adduction,  and  inward 
rotation.  Eacli  of  the  destructive  changes  of  hip  disease,  the 
enlargement  of  the  acetabulum,  tlie  depression  of  the  neck  of  the 
femur,  and  the  erosion  of  the  head  of  the  bone,  is  accompanied 


Fig.  206 


Fig.  207 


The  final  effect  of  hip  disease  when  un- 
treated. Tlie  natural  cure,  with  flexion  and 
adduction.  Compensatory  recurvation  of 
the  knee  on  the  sound  side  is  also  shown. 


Untreated  hip  di.sease.  Flexion  deform- 
ity to  nearly  a  right  angle  with  the  body. 
Trochanter  two  inches  above  Nulaton's  line. 
Compensatory  lordosis. 


by  an  elevation  of  the  femur  upon  the  pelvis  or  an  approximation 
to  a  dorsal  displacement  (Fig.  207).  If  this  disphu'ement  occurs 
suddenly,  as  in  certain  cjises  of  acute  disea,se  attended  by  efl'u- 
sion  and  rupture  of  the  capsule,  the  limb  immediately  assumes  an 


312 


ORTHOPEDIC  SUBOERY 


Fig.  20S 


attitude  typical  of  dorsal  dislocation ;  but  in  the  ordinary  form 
ofjidisease  the  changes  are  very  gradual;  the  pehis  and  the  femur, 
being  in  most  instances  undeveloped,  more  readily  accommodate 

themselves  to  the  changed  con- 
ditions, so  that  the  actual  dis- 
tortion is  less  marked  than  in  a 
similar  subluxation  of  traumatic 
origin  in  the  adult,  but  the  simile 
will  serve  to  illustrate  the  mechan- 
ical causes  of  distortion,  and  why 
such  deformity  may  recur  after 
correction,  even  though  the  disease 
has  entirely  disappeared.  Out- 
ward rotation  of  the  limb  is  usu- 
ally associated  with  abduction,  and 
inward  rotation  with  adduction, 
but  in  certain  instances  outward 
rotation  may  be  combined  with  ad- 
duction and  inward  rotation  with 
abduction.  These  irregular  atti- 
tudes are  more  often  observed  in 
cases  that  have  received  mechan- 
ical or  operative  treatment  than  in 
those  in  which  the  disease  has 
pursued  its  natural  course. 

As  has  been  stated,  the  distor- 
tions of  the  early  stage  of  hip  dis- 
ease  are   caused   almost  entirely 
by  muscular  contraction  which  re- 
laxes  under   the  influence   of  an 
anaesthetic,  but  after  a  time  the 
attitude  is  confirmed    by  accom- 
modative changes  in  the  muscles 
and  fasciae,  and  by  contractions 
and  adhesions  about  the  capsule. 
Thus  an  attitude  that  was  origi- 
nally a  symptom  may  persist  after 
the  cure  of  the  disease. 
One  may  conclude  then  that  flexion  is  practically  an  invari- 
ah)le   symptom   in   hip  disease   because   complete   extension,   the 
attitude  that  puts  most  strain  upon  the  joint,  is  first  restricted. 
Flexion  in  the  milder  or  in  the  earlier  class  of  cases  is  usually 


Stage  of  apparent  shorteniiiK.  Tlie  left 
limb  is  adducted  35°,  making  an  apparent 
Hhortening  measured  from  the  umbilicus 
of  more  than  two  inches.  In  order  to 
reduce  the  obliquity  of  the  pelvis,  the 
adducted  leg  must  be  crossed  over  its 
fellow.  (See  Fig.  204.)  The  apparent 
shortening  is  comi>ensated  by  the  flexion 
at  the  knee  on  the  sound  side.  This  is 
not  made  clear  in  the  photograph. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JO  INT  313 

combined  with  abduction  and  outward  rotation,  the  attitude  of 
inactivity.  Increased  flexion,  accompanied  by  adduction  and 
inward  rotation  in  the  early  stage,  is  an  indication  of  a  more 
acute  phase  of  the  disease.  If  the  attitude  is  retained  for  a  time 
it  becomes  fixed  by  accommodative  changes  in  the  tissues;  thus 
the  distortion  is  not  unusual  in  cases  in  which  the  damage  to  the 
joint  may  be  very  slight,  as,  for  example,  when  it  follows  rheu- 
matism or  some  form  of  infectious  arthritis.  But  in  most  instances 
the  attitude  is  indicative  of  more  advanced  disease  and  of  destruc- 
tive changes  within  the  joint. 

Changes  in  the  Contour  of  the  Hip. — In  the  early  stage  of  the 
disease  the  changes  in  contour  are  caused  in  great  part  by  the 
attitude  of  the  limb.  If,  as  is  usual,  it  is  flexed,  abducted,  and 
rotated  outward  the  buttock  appears  somewhat  flatter  and  broader 
than  its  fellow.  The  gluteofemoral  fold  is  lower  because  of  the 
tilting  downward  of  the  pelvis  and  it  is  shallower  because  of  the 
flexion.  If  the  thigh  is  adducted,  the  gluteal  fold  will  be  ele- 
vated and  shortened.  On  the  anterior  aspect,  the  inguino- 
femoral fold  is  deepened  and  lengthened  by  flexion  and  adduction 
while  abduction  makes  it  less  noticeable.  Hoffman  has  called 
attention  to  the  fact  that  the  genitals  and  the  intergluteal  fold 
point  toward  the  adducted  and  away  from  the  abducted  thigh. 
Adduction  makes  the  trochanter  more  prominent,  and  abduction 
makes  it  less  prominent. 

To  these  primary  changes  in  the  appearances  must  be  added 
the  effect  of  atrophy  or  of  infiltration  and  swelling,  due  directly 
to  the  disease.  A  certain  amount  of  swelling  indicating  effusion 
into  the  joint  is  often  apparent  in  the  inguinofemoral  region,  and 
infiltration  of  the  deeper  tissues  is  sometimes  e\ident  on  palpation. 
In  such  cases  there  is  usually  a  certain  sensitiveness  to  deep  pressure 
behind  or  in  front  of  the  trochanter.  Palpable  or  e^^dent  abscess 
is  unusual  in  the  early  stage  of  the  disease. 

Atrophy. — Atrophy  is  an  important  sign  of  joint  disease.  It  is 
often  appreciable  to  the  eye  and  to  the  hand,  and  it  is  always 
demonstrable  by  measurement.  It  is  an  important  symptom, 
because,  if  well-marked,  it  shows  that  the  disease  must  have 
existed  for  some  time,  whatever  may  be  the  statement  of  the 
patient's  relatives. 

The  atrophy  affects  the  muscles  of  the  entire  limb,  although  it 
is  somewhat  more  marked  in  the  muscles  of  the  thigh  than  in 
the  calf.  In  the  ordinary  case  of  hip  disease  in  childhooil,  when 
the  patient  is  first  brought  for  treatment,  it  averages  from  one- 


314  OR  THOPEDIC  S  UR  GER  Y 

half  to  one  inch  in  the  thigh  and  somewhat  less  in  the  calf.  As 
has  been  stated  elsewhere,  atrophy  of  muscles  is  usually  accom- 
panied by  a  corresponding  atrophy  of  bone  as  well.' 

The  Causes  of  Atrophy. — Admitting  that  the  secondary 
causes  of  atrophy  are  somewhat  obscure,  one  cause,  and  by  far 
the  most  important,  is  very  evident.  This  is  physiological  disuse, 
and  thus  diminished  nutrition  of  the  limb,  which  has  become 
incompetent  to  carry  out  its  full  function.  Atrophy  is  a  constant 
sjTnptom  of  simple  disuse  in  the  absence  of  disease.  If  a  bone 
has  been  broken,  atrophy  of  the  surrounding  muscles  is  observed. 
If  anchylosis  of  a  joint  occiu's  from  any  cause,  whether  it  be  from 
injury  or  disease,  atrophy  of  the  muscles,  whose  function  has  been 
abolished,  follows.  Even  the  atrophy  caused  by  disease  of  the 
hip-joint  is  greater  when  the  limb  has  been  fixed  in  apparatus  than 
when  none  has  been  applied,  although  the  treatment  has  allayed 
the  pain  anrl  has  checked  the  progress  of  the  disease.  This 
point  is  illustrated  by  the  observations  of  Brackett,^  who  contrasted 
the  atrophy  of  hip  disease  in  two  groups  of  patients,  in  one  of 
which  motion  had  been  permitted,  while  in  the  other  fixation,  as 
complete  as  possible,  had  been  employed.  In  the  first  group  the 
average  of  atrophy  was  but  1  per  cent,  of  the  volume  of  the  thigh 
and  0.89  per  cent,  of  that  of  the  leg,  as  contrasted  with  23  per 
cent,  and   17  per  cent,  in  the  second  class. 

According  to  the  investigations  of  Bum,^  simple  fixation  of  a 
sound  limb  induces  m;;re  rapid  atrophy  than  is  caused  by  dis- 
ease of  a  joint  when  function  has  been  permitted. 

The  atrophy  caused  by  physiological  disuse  and  diminished 
nutrition  aflects  all  the  components  of  the  limb.  The  skin  be- 
comes thinner,  the  muscles  lose  in  volume,  the  contractile  sub- 
stance is  replace<l  in  part  by  fat  and  by  fibrous  tissue,  and  the 
medullary  canals  of  the  bones  enlarge  at  the  expense  of  the  cor- 
tical substance. 

In  childhood,  the  period  of  rapid  development,  disuse  often 
causes  a  retardation  in  growth  of  the  entire  extremity.  This 
may  be  apparent  in  the  foot  when  it  is  placed  by  the  side  of  its 
fellow,  while  the  diminished  growth  in  the  length  of  the  limb 
may  be  demonstrated  by  measurement.  Brackett,  in  a  series  of 
cases,  found  this  shortening  to  be  distributed  as  follows:  average 
loss  of  the  femur  0.6  per  cent,  and  of  the  tibia  5.4  per  cent,  of 
the  normal   length. 

'  Trariaactiona  American  Orthopedic  Association,  vol.  iv. 
*  Zeit.  f.  chjr.,  December  9.  1905. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JO [i^T 


315 


This  atrophy,  the  direct  result  of  the  disease  and  of  the  long- 
continued  disuse  during  the  period  of  repair,  becomes  less  notice- 
able after  .function  is  resumed,  the  degree  of  final  inequality 
depending  upon  the  severity  of  the  disease,  the  duration  of  the 
treatment,  and  upon  the  impairment  of  function.  But  even 
when  free  motion  in  the  joint  is  retained,  a  certain  amount  of 
atrophy  always  persists  ami  the  loss  in  growth  is  never  replaced. 


l'"iG.  209 


Early  stage  of  disease   of  the   left  hip-joint   (to  the  right  in  the  picture)   ufihc    ^^Il<l\i;ll 
type,  showing  irregularity  in  tlie  shape  of  the  acetabulum. 

If  motion  is  completely  abolished  the  muscles  about  the  joint  lose 
in  bulk  in  proportion  to  the  disuse  of  their  normal  function ;  whereas 
the  bones  of  the  limb  which  are  still  used  to  support  the  weight 
retain  to  a  greater  tlegree  their  normal  size  and  length.  Contrasted 
with  this  atrophy  there  is  a  relative  hypertrophy  of  the  sound 
limb,  which  is  forced  to  assume  more  than  its  share  of  work. 


316 


ORTHOPEDIC  SURGERY 


AcTUAi.  Shortening. — Actual  shortening  of  the  limb  is  a 
common  effect  of  hip  disease,  but  it  can  hardly  be  called  a  symp- 
tom, for  it  is  not  present  at  the  onset  of  the  disease. 

The  causes  of  actual  shortening  may  be  classified  as: 

1.  Disuse  of  the  Hmb. 

2.  The  effect  of  the  disease  upon  the  epiphysis  of  the  head  of 
the   femur. 

Fig.  210 


m 

J 

1 

1 

! 

^ 

'i- 

1 

1 

1 

' 

%W^l%4i 

1 

^HHi^'* 

f 

' 

€ 

V 

'-.^IH 

^^1 

■■■ 

■'f 

*'\ 

' 

f    ■  yV-'^ 

I 

Advanced  disease,  showing  wandering  of  the  acetabulum  and  the  obliquity  of  the  pelvis 
due  to  adduction.     Actual  shortening  one  inch,  apparent  shortening  three  inches. 


3.  The   more  general   destructive  effects   of  the  disease   that 
cause  upward  displacement  of  the  femur, 
(a)  Erosion  of  the  head. 
(6)   Erosion  of  the  acetabulum, 
(c)  Depression  of  the  neck  of  the  femur. 


TUBERCULOUS  DISEASE  OF  THE  B IP-JOINT         317 

Disuse,  throughout  a  long  period  of  treatment,  causes  a  certain 
amount  of  shortening  of  the  entire  limb.  To  this  the  shorten- 
ing of  the  bones  of  the  leg  and  of  the  foot  may  be  attributed  in 
great  part.  If  the  epiphysis  of  the  head  of  the  femur  is  destroyed 
in  whole  or  in  part  or  if  the  disease  hastens  its  union  with  the 
neck  a  certain  loss  of  growth  must  follow.  This  is,  of  course, 
slight  in  degree,  because  this  epiphysis  is  relatively  unimportant 
compared  with  that  at  the  lower  extremity  of  the  femur.  From 
these  two  causes,  the  atrophy  of  disuse  and  the  effect  of  the  dis- 
ease upon  the  epiphysis,  relative  shortening  of  the  limb  may  in- 
crease after  the  disease  is  cured. 

Erosion  of  the  head  of  the  femur  and  of  the  upper  border  of 
the  acetabulum  are  usually  combined  in  those  cases  in  which  the 
shortening  is  in  part  dependent  on  upward  displacement  of  the 
trochanter  (Fig.  197).  Depression  of  the  neck  of  the  femur  to 
an  appreciable  degree  is  less  common.  Elevation  of  the  trochan- 
ter, due  to  one  or  more  of  these  causes,  a  form  of  subluxation, 
is  very  common,  particularly  so  in  those  cases  in  which  the  pro- 
tective treatment  has  been  inefficient.  Greater  displacement 
follows  fracture  of  the  weakened  neck  and  complete  absorption 
of  the  head,  and  occasionally  a  fairly  normal  femur  may  be  act- 
ually dislocated  as  a  result  of  sudden  effusion  into  the  joint  with 
rupture  of  the  capsule — a  form  of  pathological  dislocation. 

It  may  be  stated  also  that  in  partial  or  complete  displacement 
forward  (anterior  subluxation)  is  not  uncommon.  In  such  cases 
there  is  marked  outward  rotation  of  the  limb  with  but  slight 
shortening,  the  head  of  the  bone  presenting  by  the  side  of  the 
anterior  inferior  spine  of  the  pelvis. 

Retardation  of  Growth. — As  has  been  stated,  all  the  com- 
ponents of  the  limb  are  affected  by  the  retardation  of  the  growth. 
Brackett's  observations  on  this  point  have  been  mentioned,  and 
the  table  on  the  following  page,  showing  the  relative  measures 
of  the  bones  in  cases  under  treatment  by  Dollinger,^  of  Budapest, 
presents  the  subject  in  a  convenient  form : 

1  Zeits.  f.  Orth.  Chir.,  1892,  Bd.  i. 


318 


OETHOPEDIC  SURGERY 


Age  at 

Duration  of 

Len 

gth  of 

Length  of 

inception. 

disease. 

femui 

in  cm. 

tibia  in  cm. 

No.  ol 

Differ- 
ence. 

Differ- 

case. 

ence. 

Dis- 

Dis- 

Years. 

Months. 

Years. 

Months. 

eased. 

Normal. 

eased. 

Normal. 

1 

8 

6 

6 

28^2 

28 

+% 

24 

24 

•J 

3 

4 

8 

23 

24 

1 

19 

19 

% 

2 

10 

"i           8 

24 

24 

19  5 

19.5 

4 

ft 

2      i 

29 

30 

"i 

23.5 

23.5 

5 

<> 

2 

•27 

28 

1 

23 

23 

6 

7 

2 

32 

33 

1 

27 

27 

7 

9 

2 

37 

37 

30 

30 

8 

1 

4 

22 

24 

"i 

18.5 

19 

0.5 

9 

13 

4 

38 

41 

3 

34 

34 

10 

4 

"6 

5 

32 

34 

2 

27 

27 

11 

23^ 

6 

26 

27 

1 

'2\% 

23 

1" 

12 

i's 

7 

38 

40 

2 

33 

33 

13 

2 

8 

35 

36 

1 

28 

28 

14 

6 

8 

38 

38 

31 

32 

1.5 

n 

8 

40 

44 

"4 

34 

34 

16 

5 

10     ; 

45 

46 

1 

17 

5 

U     1 

41 

44 

3 

31 

37 

6" 

IS 

6 

14 

■44 

48 

4 

36 

39.5 

3.5 

19 

2 

18 

36 

46 

10 

38 

38 

20 

2 

::: 

28      1         ... 

44J^ 

45 

% 

37.5 

37.5 

A  similar  investigation  of  thirty-three  cases  under  treatment 
at  the  Hospital  for  Ruptured  and  Crippled,  New  York,  has  been 
made  recently  by  Taylor.  In  these  cases  the  shortening  of  the 
bones  was  found  to  be  more  generally  distributed  than  in  those 
reported  by  Dollinger,  as  is  illustrated  by  the  accompanying  table. 

Dr.  Taylor  measured  also  ten  cases  of  unilateral  poliomyelitis, 
in  patients  of  an  average  age  of  thirteen  years,  with  an  average 
duration  of  disability  of  ten  years.  The  average  shortening  in 
these  cases  was  one  and  three-fourths  inches,  and  in  no  case  was 
it  greater  than  two  and  one-half  inches.  It  will  be  noted  that 
the  retardation  of  growth  in  this  group  corresponds  closely  with 
that  of  the  third  group  of  cases  of  hip  disease,  in  which  the  disa- 
bility was  of  about  the  same  duration.  Taylor  concludes  that 
the  retardation  of  growth  from  unilateral  hip  disease  in  childhood 
is  dependent  in  great  degree  upon  the  duration  of  the  disability 
and  upon  the  corresponding  restraint  of  function.  Similar  obser- 
vations on  fifty  cases  of  hip  disease  have  been  recorded  by  Hibbs.^ 

Actual  Lengthening  of  the  limb  as  the  result  of  disease  is 
occasionally  observed  during  the  active  stage  of  the  disease, 
caused,  it  may  be  inferred,  by  granulations  within  the  acetabulum 
that  press  the  femur  outwanl  and  downward.  Actual  lengthen- 
ing of  the  femur  is  uncommon,  but  it  does  occur,  induced,  it  may 
be,  by  .stimulation  of  the  growth  of  the  epiphysis  of  the  head; 
but  the  most  extreme  instances  are  those  in  whicli  the  upper  por- 
tion of  the  shaft  of  the  fcrniir  is  involvcnl,  th(;  lengthening  being 


•  New  York  Medical  .Jounial,  JJeceinljor  l(i,  1899. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


31 'J 


the  effect  of  an  irritative  hypertrophy.     This  is  more  commonly 
the  result  of  extra-articular  disease. 


Dura- 

Shortening in  incbes. 

Sex. 

Age. 

Side. 

Dura- 
tion of 

tion  of 
treat- 

Abscess. 

Case. 

1 

disease, 

ment, 

Entire 

1 

years. 

years. 

limb. 

Femur.  Tibia. 

1 

Foot. 

Patella 

1 

F. 

%V, 

Left 

1 

1 

No 

y^ 

_ 

y 

% 

P 

2 

M. 

7 

Risht 

1>^ 

1 

No 

Vat 

X 

i 

3 

M. 

5 

Lett 

2 

1 

No 

% 

}i 

'4 

4 

M. 

5 

KiKht 

2 

1% 

No 

1/ 

H 

y 

5 

M. 

6K> 

Left 

2>^ 

■^% 

Yes 

% 

y* 

n 

f8 

K 

6 

V. 

4'/„ 

Leit 

3 

3 

No 

y 

7 

K. 

h»/; 

Right 

3 

— 

No 

y^ 

— 

y* 

— 

8 

M. 

6 

Right 

3 

2>^ 

No 

1% 

}i 

y 

^ 

% 

9 

T^. 

IS 

LeIt 

•i% 

2 

No 

Yx 

% 

V' 

v>. 

10 

J<'. 

7 

I.elt 

3^ 

3>^ 

No 

y% 

% 

H 

\ 

y 

n 

M. 

7 

Right 

3K 
3>| 

3^^ 

Yes 

1 

V, 

Vi 

% 

% 

Vl 

F. 

11 

Kight 

ly. 

No 

^H 

M 

% 

y 

y^. 

13 

!<'. 

9 

Left 

I        3>^ 

1 

■i% 

No 

IK 

K 

y. 

% 

Average 

7    1     ... 

2>^ 

2 

...    1     y. 

Vs  . 

H 

K 

% 

M. 

7 

Right 

F. 

MVo 

Right 

1''. 

12 

Kight 

F. 

11 

Right 

F. 

13 

Lett 

F. 

12 

Left 

F. 

10 

Left 

M. 

14 

Left 

F. 

l.") 

Right 

M. 

yx 

Right 

4 
4 

5^ 


^y> 


Average      11 


5% 


4 

No 

1 

r* 

4 

No 

1 

y 

4 

Yes 

31/ 

% 

4 

Yes 

2'X 

1 

;< 

No 

•) 

% 

4 

No 

% 

y. 

4 

No 

^y 

y 

X 

\es 

•^y-i 

X 

h 

No 

2ll 

X        ' 

'A 

Yes 

v-A 

—     1 

sx 

m 

%  1 

y 
1 


24 

F. 

13 

Right 

25 

.M. 

M^ 

Right 

26 

M. 

10% 

Right 

27 

K. 

1« 

Rmhi 

2.S 

M. 

IS 

Kisfht 

2H 

F. 

15 

Left 

xn 

F. 

15 

Right 

HI 

v. 

15 

Right 

32 

F. 

16 

Left 

33 

F. 

21 

Left 

8 

7 

Yes 

•^y 

y 

<) 

() 

"\es 

i'A 

2 

!» 

X 

No 

iM 

^ 

9 

7 

No 

■-'K 

X 

n 

10 

Yes 

2 

'4 

11 

/ 

Yes 

3 

11 

5 

Yes 

1 

y 

11% 

!'>^ 

Yes 

3 

K 

14 

1 

No 

1>^ 

H 

17 

6 

Yes 

5J^ 

2^ 

1^ 

lii 

1 
1 


Average 


15 

11               6 

2% 


y 


% 


—  Measurements  equal.  x  Measurements  not  taken. 

Measurements  of  the  femur  from  the  apex  of  the  great  trochanter  to  the  knee  joint.  Patella 
measured  transversely.  The  eases  are  grouped  according  to  the  duration  of  disease  and  the 
averages  are  given  separately  for  each  group. 

General  Symptoms  of  the  Disease.  Debility.— If  the  disease 
is  sufficiently  painful  to  cause  loss  of  sleep  and  to  affect  the  ap- 
petite, pallor  and  loss  of  flesh  and  strength  may  be  expected. 
It  must  l)e  borne  in  mind,  however,  that  the  patient  may  have 
been  delicate  long  before  the  local  tuberculous  disease  was  ac- 
quired. At  all  events  from  the  diagnostic  standpoint  at  least, 
the  local  disease  has  no  characteristic  influence  upon  the  general 


320  ORTHOPEDIC  SURGERY 

condition,  and  the    appearance  of  perfect   health  is   not  at  all 
unusual  among  patients  with  hip  disease. 

Fever. — It  is  probable  that  a  slight  elevation  of  temperature 
might  be  detected  in  a  large  proportion  of  the  patients,  and  in 
such  cases  actual  appreciable  fever  often  follows  overexertion  of 
injury.  Fever,  as  a  symptom  of  infected  abscess  in  the  later 
course  of  the  disease,  is,  of  course,  of  importance,  but  in  the  early 
stages  of  the  disease  the  record  of  the  temperature  would  be  of 
but  little  diagnostic  value. 

The  History  and  the  Method  of  Examination. — In  consider- 
ing the  differential  diagnosis  of  tuberculous  disease  of  the  hip- 
joint  one  should  keep  its  characteristics  in  mind.  It  is  a  chronic 
disease,  in  that  the  symptoms  may  have  been  present  for  weeks 
or  months  or  even  years  before  the  patient  is  brought  for  treatment. 
It  is  a  disease  confined  to  a  single  joint,  thus  differing  from  rheu- 
matism and  similar  affections  in  which  several  joints  are  involved. 
It  does  not  get  well;  thus  it  may  be  differentiated  from  injury 
and  from  the  minor  affections  that  simulate  some  of  its  symptoms. 
It  causes  a  limp.  It  is  accompanied  by  reflex  muscular  spasm, 
usually  by  a  certain  amount  of  deformity  and  by  general  atrophy 
of  the  muscles  of  the  limb. 

The  importance  of  the  inheritance  and  of  the  personal  history 
of  the  patient  has  been  mentioned  already  in  the  consideration 
of  Pott's  disease.  In  recording  the  history  in  this  as  in  all  other 
chronic  diseases  of  childhood  one  attempts  to  ascertain  the  ap- 
proximate duration  of  the  pathological  process  rather  than  the 
duration  of  the  more  acute  symptoms  for  which  the  patient  has 
been  brought  for  treatment.  One  asks,  therefore,  when  the 
chilfl  was  last  perfectly  well,  and,  bearing  in  mind  the  remission  of 
symptoms,  one  asks  if  limp  or  pain  had  been  noticed  at  any  time 
before  the  more  acute  symptoms.  In  the  history  there  is  almost 
invariably  mention  of  a  fall,  and  one  must  ascertain  whether  the 
fall  had  any  influence  in  the  causation  of  the  symptoms,  remem- 
bering that  the  weakness  and  interference  with  function  due  to 
joint  disease  more  often  cause  falls  than  falls  cause  joint  disease. 

Physical  Examination. — One  begins  the  physical  examination  by 
the  observation  of  the  general  condition  of  the  patient,  and  notes 
the  attitutles,  and  the  character  of  the  limp.  The  patient's  cloth- 
ing is  then  entirely  removed,  that  one  may  observe  the  contour 
of  the  part  and  the  general  influence  of  the  affection  upon  the 
mechanism  of  the  body.  The  patient  is  then  placed  on  his  back 
upon  a  table,  with  the  limbs  parallel  to  one  another,  so  that  their 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  321 

relative  length  and  size  may  be  observed.  If  the  pelvis  is  level 
when  the  limbs  are  parallel,  there  can  be  no  persistent  abduction 
or  adduction,  for  when  the  two  anterior  superior  spines  are  on 
the  same  plane  such  distortion  is  always  evident.  If  the  lumbar 
spine  and  the  popliteal  surfaces  of  the  knees  rest  on  the 
table  simultaneously  it  shows,  too,  that  persistent  flexion  is  absent. 
One  next  tests  the  function  of  the  hip-joints,  always  beginning 
with  the  sound  side  for  the  purpose  of  comparison,  and  in  order 
that  the  patient  may  become  accustomed  to  the  manipulation 
before  the  one  suspected  of  disease  is  tested.  Disease  within 
a  joint  is  accompanied  by  muscular  spasm  that  limits  motion  in 
every  direction,  thus  differing  from  other  affections  outside  the 
joint  that  may  limit  its  motion  in  one  or  more  but  not  in  all 
directions. 

One  compares  the  flexion,  abduction,  adduction,  and  rotation 
of  the  limbs  while  the  child  lies  upon  its  back;  it  is  then  turned 
upon  its  face  to  test  for  extension  by  holding  the  pehds  flat  upon 
the  table  with  one  hand  while  the  thigh  is  gently  elevated  with 
the  other  (Fig.  16).  The  normal  range  of  extension  in  child- 
hood is  about  twenty  degrees  backward  from  the  line  of  the 
body,  and  limitation  of  this  range  is  the  earliest  indication  of  the 
deformity  of  hip  disease.  It  may  precede  the  restriction  of  the 
extremes  of  motion  in  other  directions,  although  this  is  unusual, 
and  if  this  motion  is  unrestricted  disease  of  the  joint  may  be, 
practically  speaking,  excluded.  The  character  of  the  reflex 
spasm  that  limits  motion  and  the  indications  of  discomfort  when 
the  limit  has  been  reached  have  been  described. 

Measurements. — The  measurements  of  the  limbs  are  then  made. 
One  first  ascertains  the  actual  length  of  the  limbs  by  measur- 
ing from  the  anterior  superior  spines  of  the  pehis  to  the  extremi- 
ties of  the  internal  malleoli,  actual  shortening  being  of  course 
absent  in  the  early  stage  of  the  disease.  The  second  measure- 
ment is  from  the  umbilicus  to  show  the  amount  of  apparent 
shortening  or  lengthening  that  may  be  present  if  the  limb  is  dis- 
torted. The  actual  length  of  the  limbs,  as  measured  from  the 
anterior  superior  spines,  is  but  slightly  affected  by  tilting  of  the 
pelvis,  but  as  the  umbilicus  is  in  the  middle  line  of  the  body  above 
the  pehns  measurement  from  this  point  simply  shows  the  actual 
distance  to  the  malleoli.  Persistent  adduction  causes  compensa- 
tory obliquity  of  the  pelvis;  consequently  the  malleolus  on  the 
affected  side  is  drawn  upward  or  nearer  to  the  umbilicus,  while 
the    other    is    carried    downward  to    a    corresponding   distance 

21 


322  OBTHOrEDlC  SURGEEY 

(Fig.  208).  If,  then,  the  measurements  from  the  umbihcus  to  the 
malleoH  tlo  not  correspond  relatively  with  those  from  the  anterior 
superior  spines,  when  the  limbs  are  parallel  and  in  the  median 
line,  it  shows  distortion;  adduction,  if  the  limb  is  relatively  shorter, 
abduction,  if  it  is  relatively  longer  than  is  shown  by  the  measure- 
ment from  the  anterior  superior  spine.  It  has  been  stated  that 
the  measurement  from  the  nnterioi"  superior  spine  is  not  greatly 
change  by  distortion.  It  is,  however,  shortened  by  abduction,  and 
it  is  correspondingly  lengthened  by  adduction.  This  is  explained  as 
f cillows :  AMien  the  limb  is  in  the  line  of  the  body  the  trochanter 
is  below  the  anterior  superior  spine  from  which  the  measurement 
is  made.  Abduction  of  the  limb  raises  the  trochanter  toward 
the  plane  of  the  anterior  superior  spine,  and  consequently  lessens 
the  distance  from  this  point  to  the  extremity  of  the  limb.  Adduc- 
tion, on  the  contrary,  lowers  the  trochanter  and  increases  the 
distance  between  these  two  points.  Ordinarily  the  variation 
from  this  source  does  not  exceed  half  an  inch.  But  if  the  dis- 
tortion is  extreme  the  error  must  be  corrected  if  the  measure- 
ments are  to  be  approximately  accurate.  Flexion  of  one  thigh 
causes  a  tilting  forward  of  the  pelvis  that  lessens  the  distance 
between  the  anterior  superior  spine  and  the  malleolus  on  both 
sides,  although  not  to  an  equal  degree.  It  is  customary,  there- 
fore, if  the  flexion  is  considerable,  to  raise  the  unaffected  limb 
to  the  line  of  its  fellow  in  making  the  comparative  measurements, 
stating  in  the  record  that  the  limbs  have  been  measured  at  the 
angle  of  the  deformity  and  are  therefore  shortened. 

]\Iethod  of  Estimating  the  Degree  of  Distortion  of 
THE  Limb. — As  has  been  stated,  when  the  pelvis  is  level,  distor- 
tion of  the  limb  is  apparent,  and  the  degree  of  distortion  can  be 
measured  by  tlie  goniometer  (Fig.  204);  but  it  may  be  more  easily 
ascertained  by  "Lovett's  table."^  This  method  is  described 
by  its  author  as  follows: 

'    H.   W.  lyovett,    Boston   Medical  and  Surgical  ■Journal,  Maich  S,  1888. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOiyT         223 
Table  I.— Distance  between  Anterior  Superior  Spines  in  Inches. 


3 

3% 

4 

4K 

"M 

W-, 

6 

W^ 

7 

7K 

8 

8J^ 

9 

W^ 

10 

11 

12 

13 

tab 

•  K 

50  40 

40 

8° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

2° 

1° 

10 

1° 

1° 

1° 

a 
"S 

y2 

10  ;   8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 

3 

3 

3 

2 

o 

r] 

% 

14 

12 

11 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

4 

4 

4 

3 

3 

1 
S 

1 

19 

17 

14 

13 

11 

10 

9 

9 

8 

7 

7 

7 

6 

6 

6 

5 

5 

4 

IK 

25 

21 

18 

16 

14 

13 

12 

11 

10 

9 

9 

8 

8 

7 

7 

7 

6 

6 

1 

ij^ 

30 

25 

22 

19 

17 

15 

14 

13 

12 

12 

11 

10 

10 

9 

9 

8 

7 

7 

c 

83 

IK 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8 

8 

2 

42 

35 

30 

26 

23 

21 

19 

18 

16 

15 

14 

14 

13 

12 

13 

10 

10 

« 

^  ■ 

'^J4 

...  1  40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11 

10 

IK 

2>^ 

39 

34 

29 

27 

24 

22 

h 

19 

18 

17 

16 

15 

14 

13 

12 

11 

2K 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13  12 

c 

3 

42 

35 

32 

29 

27 

25 

23 

22 

21 

39 

18 

18 

16 

14  :  12 

314 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15  14 

Ci 

o 

p 

33^ 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17  16 

0) 

33^ 

... 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

■fi 

.  4 

... 

42 

38 

35 

32 

30 

28 

26 

25 

23 

21 

19 

18 

"To  measure  by  this  method  the  patient  is  made  to  lie  straight 
with  the  legs  parallel.  Real  shortening  is  measured  .witli  the 
ordinary  tape  measure,  and  apparent  shortening  is  obtained  in 
the  same  way.  It  may  be  repeated  that  real  or  bony  shortening 
is  measured  from  the  anterior  superior  iliac  spines  to  each  mal- 
leolus, and  that  practical  shortening  is  found  by  a  measurement 
taken  from  the  umbilicus  to  each  malleolus.  The  difference  in 
inches  between  the  two  kinds  of  shortening  is  seen  at  a  glance. 
The  only  additional  measurement  necessary  is  the  distance  be- 
tween the  anterior  superior  spines,  which  is  taken  with  the  tape. 
Turning  now  to  the  table:  if  the  line  which  represents  the  amount 
of  difference  in  inches  between  the  real  and  apparent  shorten- 
ing is  followed  until  it  intersects  the  line  which  represents  the 
pelvic  breadth,  the  angle  of  deformity  will  be  found  in  degrees 
where  they  meet.  //  the  practical  shortening  u  greater  than 
the  real  shortening,  the  diseased  leg  is  adducted;  if  less  than  real 
shortening,  it  is  abducted.  Take  an  example:  Length  (from 
anterior  superior  spine)  of  riglit  leg,  23;  left  leg,  22i;  lengtli 
(from  umbilicus)  of  right  leg,  25;  left  leg,  23;  real  shortening, 
|-  inch;  apparent  shortening,  2  inches;  tlifference  between 
real   and   practical    shortening,    Ih    inches;  pelvic  me:i,surement. 


324 


ORTHOPEDIC  SURGERY 


7  inches.  If  we  follow  the  line  for  1^  inches  until  it  intersects 
the  line  for  peh-ic  breadth  of  7  inches,  we  find  12  degrees  to  be  the 
angular  deformity,  as  the  practical  shortening  is  greater  than  the 
real,  it  is  12  degrees  of  adduction  of  the  left  leg.  If  apparent 
lengthening  is  present  its  amount  should  be  added  to  the  amount 
of  actual  shortening." 

If  flexion  is  present  the  degree  may  be  ascertained  by  raising 
the  flexed  limb  imtil  the  lumbar  spine  touches  the  table,  when  the 
angle  formed  by  the  thigh  with  the  body  may  be  measured  with 
the  goniometer  (Fig.  203),  or  its  degree  may  be  ascertained  by 
Kingsley's  table. 

"The  patient  Hes  upon  a  table  flat  on  his  back  and  the  surgeon 
flexes  the  diseased  leg,  raising  it  by  the  foot  until  the  lumbar 


Fig.  211 


A  C 

Kingsley's  method  of  estimating  flexion. 


vertebrae  touch  the  table,  showing  that  the  pelvis  is  in  the  correct 
position.  The  leg  is  then  held  for  a  minute  at  that  angle,  the 
knee  being  extended,  while  the  surgeon  measures  off  two  feet  on 
the  outside  of  the  leg  with  a  tape  measure,  one  end  of  which  is 
held  on  the  table,  so  that  the  tape  measure  follows  the  line  of 
the  leg  {A  B).  From  this  point  on  the  leg  {B)  where  the  two 
feet  reach  by  the  tape  measure  one  measures  perpendicularly 
to  the  talkie  {B  C),  and  the  number  of  inches  in  the  line  B  C  can 
be  read  as  degrees  of  flexion  of  the  thigh  by  consulting  Table  II. 
For  instance,  if  the  distance  between  the  point  on  the  leg  and  the 
table  is  12^  inches  it  represents  31  degrees  of  flexion  deformity 
of  the  thigh. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT 
Table  II.i 


325 


0. 5  inches. 

1° 

6. 5  Inches. 

16<^ 

12.5  inches. 

31° 

18.5  inches. 

50° 

1.0 

2 

7.0 

17 

13.0 

33 

19.0 

52 

1.5 

3 

7.5 

19 

13.5 

34 

19.5 

54 

2.0 

4 

8.0 

20 

14.0 

36 

20. 0 

56 

2.5 

6 

8.5 

21 

14.5 

37 

20.5 

58 

3.0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3.5 

9 

9  5 

24 

15.5 

40 

21.5 

63 

4.0 

10 

10.0 

25 

16.0 

42 

22.0 

67 

4.5 

11 

10.5 

27 

16.5 

43 

22.5 

70 

5.0 

12 

11.0 

28 

17.0 

45 

23.0 

75 

5.5   " 

14 

11.5 

29 

17.5 

47 

23.5 

80 

6.0 

15 

12.0 

30 

18.0 

48 

24.0 

90 

"If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off 
twenty-four  inches  one  can  measure  twelve  inches;  ascertain  from 
here  the  distance  to  the  surface  on  which  the  patient  is  lying  in  a 
perpendicular  line  in  the  same  way,  then  doubling  this  distance 
and  looking  in  the  table  as  before  the  amount  of  flexion  is  found." 

Atrophy. — The  circumference  of  the  thighs,  the  knees,  and 
the  calves  is  then  measured  at  corresponding  points  to  test  for 
atrophy  or  for  other  irregularities  that  may  require  explanation. 
The  atrophy  of  joint  disease  affects  the  entire  limb,  and  it  is  an 
unfailing  symptom  except  in  the  earliest  stage  of  the  disease.  It 
might  be  concealed  in  the  thigh  by  a  deep  abscess,  but  it  would 
still  appear  in  the  calf. 

Local  Signs  of  Disease. — The  hip-joint  is  so  concealed  by  the 
overlying  tissues  that  the  local  sensitiveness  and  swelling  which 
usually  accompany  similar  disease  at  the  knee  and  ankle  are  often 
absent.  Firm  pressure  before  or  behind  the  trochanter,  or  over 
the  head  of  the  femur  usually  causes  some  discomfort,  however. 
In  many  instances  a  peculiar  resistance  of  the  deeper  parts,  caused 
by  infiltration  of  the  tissues  that  cover  the  joint,  is  evident  on 
palpation;  and  swelhng  about  the  joint  and  thigh,  caused  by 
effusion  or  by  deep  abscess,  is  not  unusual  when  patients  are  first 
brought  for  treatment.  Sensitiveness  of  the  skin  and  local  eleva- 
tion of  the  temperature  may  be  present  if  the  disease  is  acute, 
particularly  if  an  abscess  is  on  the  point  of  breaking  through  the 
skin. 

The  diagnosis  of  tuberculous  disease  of  the  hip,  except,  per- 
haps, in  the  stage  of  inception,  is  in  most  instances  evident  on 
a  systematic  examination,  such  as  has  been  outlined,  and  it  is 
probable  that  errors  are  due  rather  to  a  neglect  of  such  examina- 
tion than  to  any  particular  obscurity  that  tlie  ordinary  case  may 
offer. 

•  G.  L.  Kingsley,  Boston  Medical  and  Surgical  Journal,  ,TuIy  5,  1SS8. 


326  ORTHOPEDIC  SURGERY 

Diagnosis.  Local  Irritation. — Strains  of  tlie  muscles  of  the 
thigh,  enlarged  glands  in  the  groin,  irritation  or  disease  of  the 
genitals  may,  in  infancy  or  early  childhood,  cause  persistent  flex- 
ion of  the  thigh  and  pain  on  motion.  Simple  muscular  strains 
quickly  recover,  \\'hile  the  inflamed  glands  and  other  causes 
of  local  irritation  are  usually  apparent  on  inspection. 

"Growing  Pains." — So-called  growing  pain  is  probably  due  in 
many  instances  to  strain  of  the  muscles  or  to  injury  about  the 
hip;  in  other  cases  it  may  be  explained  by  rheumatism. 

Local  Injury. — It  would  appear  that  injury,  often  of  a  trivial 
character,  may  cause  congestion  in  the  neighborhood  of  the 
epiphyseal  cartilage  of  the  head  of  the  femur  and  that  injury  of 
this  character  in  delicate  children  may  be  a  predisposing  cause 
of  tuberculous  disease.  Such  a  sensitive  condition  causes  a 
limp,  pain,  or  discomfort  on  overuse  and  restriction  of  motion. 
These  S}Tnptoms  may  last  a  few  days  or  a  few  weeks;  they  may 
disappear  and  recur  from  time  to  time,  and  they  can  only  be 
distinguished  from  those  of  incipient  disease  by  continued  obser- 
vation.    (See  also  Fracture  of  the  Neck  of  the  Femur.) 

Synovitis. — In  certain  cases  of  injury  synovial  effusion  may  be 
present,  although  this  is  unusual. 

In  the  cases  in  which  the  functional  disturbances  is  caused  by 
local  irritation  or  by  slight  strain  the  symptoms  are  of  sudden 
onset  and  are  evidently  of  trivial  importance,  but  if  there  is  any 
doubt  as  to  the  diagnosis  the  hip  should  be  bandaged  and  the 
patient  should  remain  in  bed  or  at  rest  until  the  complete  sub- 
sidence of  the  symptoms  or  their  persistence  makes  the  diagnosis 
clear. 

Anterior  Poliomyelitis. — Occasionally  anterior  poliomyelitis  may 
be  accompanied  by  pain  on  motion  in  the  affected  limb  before 
paralysis  is  apparent,  but  in  a  few  days  at  most  the  diagnosis  is 
evident. 

Rheumatism. — Rheumatism  is  usually  of  sudden  onset.  It  is 
almost  always  migratory  in  character  and  it  is  accompanied  by 
fever.  If  it  were  confined  to  a  single  joint,  as  is  sometimes  the 
case  in  young  children,  and  if  the  history  were  obscure,  the  diag- 
nosis might  be  uncertain  for  a  time.  In  such  cases  appropriate 
remedies  should,  of  course,  be  employed. 

Scurvy. — Tliis  is  also  an  affection  whose  symptoms  are  general 
in  character.  It  is,  therefore,  more  likely  to  be  confounded  with 
rheumatism  than  with  a  local  disease.  In  rare  instances  one 
joint  only  appears  to  be  involved,  but  this  is,  as  a  rule,  the  knee 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  327 

rather  than  the  hip.     Pain  on  motion  of  the  hmbs,  in  an  infant 
artificially  fed,  always  suggests  scurvy. 

Infectious  Arthritis  and  Epiphysitis.— ]\lild  forms  of  infectious 
arthritis  may  follow  scarlet  fever,  diphtheria,  pneumonia,  and,  in 
a  more  severe  and  destructive  form,  typhoid  fever.  As  a  rule, 
however,  several  joints  are  involved,  and,  although  the  affection 
might  be  mistaken  for  rheumatism,  it  could  hardly  be  confoinided 
with  local  tuberculous  disease. 

Infectious  arthritis  or  epiphysitis  of  the  hip-joint  is  not  im- 
common  in  early  infancy.  It  is  of  sudden  onset,  accompanied  bv 
high  fever  and  by  constitutional  disturbance.  These  symptoms, 
together  with  the  local  heat  and  swelling,  caused  by  the  rapid 
formation  of  pus,  show  the  character  of  the  affection  and  indicate 
the  necessity  for  prompt  surgical  intervention. 

Gonorrhoeal  arthritis  is  a  form  of  joint  infection  that  in  arlult 
age  may  resemble  somewhat  the  subacute  form  of  tuberculous  dis- 
ease. As  a  rule,  however,  it  is  of  sudden  onset  and  is  evidently 
associated  with  the  local  disease. 

Extra-articular  Disease. — Disease  in  the  neighborlioo  I  of  the 
joint,  as  of  the  trochanter  or  of  the  tuberosity  of  the  ischium, 
may  cause  a  limp  and  pain;  in  most  instances  the  local  sensi- 
tiveness and  local  swelling  indicate  the  seat  of  the  disease,  while 
motion  of  the  joint  is  limited  only  in  the  directions  that  cause 
tension  on  the  sensitive  parts. 

Osteoarthritis  of  the  Hip. — Osteoarthritis  at  the  hip-joint  may  be 
mistaken  for  tuberculous  disease,  and  at  times  the  diagnosis  may  be 
obscure.  This  is,  however,  a  disease  of  adult  life,  and  it  is  in  most 
instances  accompanied  by  other  evidences  of  a  general  affection. 
The  general  form  of  rheumatoid  arthritis  in  childhood  may  begin 
in  a  single  joint.  The  pain  may  be  severe,  and  there  may  be 
muscular  spasm  and  distortion  of  the  limb.  The  diagnosis  is 
usually  made  clear  by  the  successive  involvement  of  other 
joints. 

Pott's  Disease. — Disease  of  the  lumbar  region  of  the  spine  before 
the  stage  of  deformity,  when  the  pain  is  referred  to  the  lower 
extremities,  and  in  which  unilateral  psoas  contraction  causes  a 
limp,  is  often  mistaken  for  hip  disease,  although  the  distinc- 
tion between  them  is  very  clear.  Psoas  contraction  limits  ex- 
tension only;  all  the  other  movements  of  the  limb  are  unrestrained. 
The  muscular  spasm,  of  which  the  psoas  contraction  is  a  part, 
is  a  spasm  of  the  muscles  of  the  spine  about  the  seat  of  disease, 
as  is  evident  on  examination.     Other  causes  of  psoas  contraction 


328  ORTHOPEDIC  SURGERY 

have  been  mentioned  in  the  consideration  of  Pott's  disease.  In 
exceptional  cases  active  disease  of  the  lower  region  of  the  spine 
in  young  children  may  set  up  spasm  of  tlie  muscles  about  tlie 
hip,  and  vice  versa,  so  that  it  may  be  impossible  to  decide  at  the 
first  examination  whether  tlie  irritation  is  in  the  hip  or  in  the 
spine   or  in  both. 

Sacroiliac  Disease. — Disease  of  the  sacroiliac  junction  is  very 
uncommon  in  childhood.  The  symptoms  and  the  attitude  re- 
semble sciatica  rather  than  hip  disease.  There  is  local  pain  at 
the  seat  of  disease  upon  lateral  pressure  on  the  pelvis,  and  if  the 
peh-is  be  fixed  the  motion  at  the  hip-joint  will  be  found  to  be 
free  and  painless. 

Pelvic  Disease. — Localized  disease  of  one  of  the  pelvic  bones 
may  cause  discomfort  and  a  limp.  The  cause  of  the  symptoms  is 
usually  explained  by  the  appearance  of  an  abscess. 

Disease  of  the  Bursse  about  the  Joint. — Inflammation  of  the 
bursse  about  the  hip  may  cause  local  swelling  and  sensitiveness, 
a  limp  and  limitation  of  motion  in  certain  directions,  but  the 
characteristic  muscular  spasm  of  hip  disease  is  absent.  Iliopsoas 
bursitis  forms  a  fluctuating  swelling  in  Scarpa's  space,  gluteal 
bursitis  a  localized  swelling  of  the  buttock. 

Coxa  Vara. — Depression  of  the  neck  of  the  femur  is  a  simple 
deformity.  It  causes  a  limp  and  more  or  less  discomfort,  but 
the  character  of  the  deformity,  shown  by  the  actual  shortening 
and  by  the  elevation  and  prominence  of  the  trochanter  dis- 
tinguishes it  from  hip  disease,  in  which  these  are  late  symp- 
toms. In  coxa  vara  there  is  unequal  limitation  of  motion, 
abduction,  flexion,  and  inward  rotation  being  somewhat  restricted, 
while  extension,  the  first  motion  limited  in  hip  disease,  is  as  a 
rule  not  affected. 

Fracture  of  the  Neck  of  the  Femur  in  Childhood  or  Traumatic 
Coxa  Vara. — Fracture  of  the  neck  of  the  femur  in  childhood  is 
often  of  what  may  be  termed  the  green-stick  variety,  a  depression 
of  the  neck  of  the  femur  without  actual  separation  of  the  frag- 
ments; and  in  many  instances  the  patients  are  able  to  walk  about 
within  a  short  time  after  the  accident.  In  such  cases  the  limp 
and  discomfort,  attended  during  the  stage  of  repair  by  a  certain 
degree  of  muscular  spasm,  are  often  mistaken  for  the  symptoms 
of  disease.  The  history  of  the  accident  followed  by  immediate 
disability,  the  shortening  and  the  elevation  of  the  trochanter 
are  usually  sufficient  to  exclude  disease.  In  doubtful  cases  the 
ar-ray  may  be  required  to  establish  the  diagnosis. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         329 

Congenital  Dislocation  of  the  Hip. — Congenital  dislocation  of 
the  hip  causes  a  limp,  but  it  is  a  limp  that  has  existed  since  the 
child  began  to  walk  and  that  is  unaccompanied  by  the  symptoms 
of  disease.  The  nature  of  the  disability  should  be  apparent  on 
examination. 

Hysterical  Joint. — In  hysterical  subjects  a  limp,  apparent  pain, 
and  distortion  of  the  limb,  often  following  shght  injury,  may 
simulate  disease.  Hysteria  is  very  uncommon  at  the  period  of  hfe 
in  which  tuberculous  disease  is  most  frequent.  Patients  of  this 
class  usually  present  other  symptoms  of  hysteria;  the  characteristic 
signs  of  disease,  muscular  spasm  and  atrophy,  are  absent  while 
while  the  apparent  discomfort  and  the  vouluntary  distortion  are 
quite  out  of  proportion  to  the  physical  evidences  of  injury  or 
disease. 

The  X-ray  in  Diagnosis. — Roentgen  pictures  are  of  far  more 
value  in  demonstrating  deformity  than  in  establishing  early  diag- 
nosis of  disease,  especially  of  the  hip  in  early  childhood,  when  so 
large  a  part  of  the  extremity  of  the  femur  is  cartilaginous;  the 
only  constant  indications  of  disease  being  atrophy  of  the  shaft 
of  the  femur  and  a  blurred  outline  "fogginess"  of  tlie  parts 
actually  involved.  The  pictures  are  of  value,  however,  in  show- 
ing the  destructive  effect  of  the  disease  on  the  head  of  the  femur 
or  acetabulum,  and  thus  giving  one  a  clearer  conception  of  the 
actual  condition  of  the  joint  than  would  be  possible  other^vise 
(Fig.  209).  In  older  subjects  it  may  be  possible  to  demonstrate 
the  presence  of  disease  in  the  interior  of  the  bone  by  this  means, 
but  in  any  event  Roentgen  pictures  are  of  value  only  when  in- 
terpreted by  knowledge  of  the  physical  signs. 

Method  of  Recording  a  Case. — ^The  record  should  contain  the 
general  history  of  the  patient  together  with  an  account  of  the 
more  important  symptoms,  and  of  the  treatment  that  may  have 
been  employed.  The  physical  examination  should  include  the 
weight  and  height  for  comparison  with  the  normal  standard,  and 
as  a  basis  on  which  to  judge  the  future  progress  of  the  case.  Then 
follows  a  brief  description  of  the  gait  and  attitude,  of  the  char- 
acter of  the  distortion,  if  it  be  present,  and  of  the  changes  from 
the  normal  contour.  If  restriction  of  motion  is  present,  its  causes 
are  stated  if  possible;  whether,  for  example,  it  is  due  to  simple 
muscular  spasm  or  in  part  to  adhesions  and  contractions. 

The  presence  or  absence  of  heat  and  swelling,  of  abscesses, 
sinuses,  and  the  like  is  indicated.  If  there  is  actual  shortening 
of  the  limb  its  causes  and  distribution  should  be  stated;  whether 


330  ORTHOPEDIC  SURGERY 

it  is  the  result  of  simple  retardation  of  growth  or  of  elevation  of 
the  trochanter,  as  may  be  ascertained  by  Nekton's  line  and  by 
Bryant's  triangle. 

If  the  elevation  is  due  in  great  part  to  the  enlargement  of  the 
acetabulum,  while  the  upper  extremity  of  the  femur  remains 
fairly  normal  in  shape,  the  projection  of  the  trochanter  is  more 
noticeable,  and  the  distortion  of  the  limb  in  adduction  is  greater, 
than  when  the  elevation  is  the  result  of  destruction  of  the  head 
of  the  bone.  In  this  class  of  cases  Roentgen  pictures  are  of  ser- 
vice in  showing  the  actual  condition  of  the  joint  (Fig.  210). 

A  condensed  account  of  the  more  important  points  in  the 
physical  examination  may  be  presented  by  the  formula  used  at 
the  Hospital  for  Ruptured  and  Crippled,  as  follows:  R.A. — R.U. 
— R.T.— R.K.— R.C.— A.G.E.— A.G.F.— A.S.P.— L.A.— L.U.— 
L.T.— L.K.— L.C. 

"A"  indicates  the  distance  from  the  anterior  superior  spines 
to  the  internal  malleoli. 

"U,"  from  the  umbilicus  to  the  same  points. 

"T,"  "K,"  and  "C,"  the  circumferences  of  the  limb  at  the 
thighs,  knees,  and  calves. 

"A.G.E.,"  indicates  the  angle  of  greatest  extension. 

"A.G.F,,"  the  angle  of  greatest  flexion.  Thus  the  restriction 
of  the  range  of  anteroposterior  motion  at  the  hip  is  shown  by 
these  measurements. 

"A.S.P,"  is  the  transverse  diameter  of  the  pelvis  between  the 
anterior  superior  spines,  the  measurement  required  in  Lovett's 
table  for  ascertaining  the  degree  of  lateral  distortion. 

If,  for  example,  the  record  reads: 

R.A.  181— R.U.  20  — R.T.  11  — R.K.  SJ— R.C.  7|— A.G.E.  150— A.S.P.  7 
L.A.  18-]— L.ll.  21',— L.T.  10.1— L.K.  8i— L.C.  71— A.G.F.    90 

it  would  show  at  a  glance  that  there  was  no  real  shortening,  that 
the  limb  was  abducted  because  of  the  one  and  a  quarter  inches 
of  apparent  lengthening,  according  to  the  table,  the  equivalent 
of  10  degrees  of  abduction.  It  would  show  that  there  was  per- 
manent flexion  of  30  degrees  and  a  range  of  motion  between 
the  limits  of  flexion  and  extension  of  GO  degrees,  as  compared 
with  the  normal  of  about  130  degrees. 

The  following  details  of  the  one  thousand  cases  of  hip  disease 
investigated  for  me  by  Ashley  are  of  interest  as  illustrating  the 
character  of  the  cases  treated  at  the  Hospital  for  Ruptured  and 
Crippled : 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


331 


The  Duration  of  Disease  when  Treatment  was  Begun. 


Three  months  or  less  . 
Three  to  six  months 
Six  months  to  one  year 
One  year  .... 
Two  years  .... 
Three  years  .... 


396 

170 

80 

124 

75 

29 


Four  years 21 

Five  years 17 

From  five  to  ten  years  .  35 

From  ten  to  forty  years  16 

Not  stated 37 

1000 


The  Degree  of  Deformity  Present  on  First  Examination. 


No  deformity 
6  degrees  of  flexion 

10      

15  

20  

25  

30  

35  

40 

45  

50  


130 

55  degrees  of  flexion 

44 

60        

89 

65 

69 

70        

118 

75        

32 

80         

135 

85        

56 

90        

70 

More  than  90 

41 

Not  stated     . 

68 

Restriction  of  Motion  .\t  First  Examin.\tion. 


10 
26 

8 
22 

2 
11 

1 
12 

1 
55 

1000 


Normal  motion 


30 


A  range  of  motion  through  105  degrees 14 


90 
75 
60 
45 
30 
15 
5 


No  motion 
Not  stated 


65 
,   49 

95 
,  67 
,  112 
,  95 
,  157 
.  147 
.  169 

1000 


Attitude  op  the  Limb  at  First  Examination. 

Flexion  to  a  greater  or  less  degree 814 

No  flexion 130 

Not  stated 56 


Other  Distortions  Recorded. 

Abduction 

Adduction 

External  rotation 

Internal       "  

Actual  Shortenino  whem  Treatment  was  Begun. 


1000 


254 

167 

166 

58 


K  inch 129 


1 

IK 
2 


29 

2}4  inches 

43 

2H     " 

22 

2%     " 

51 

3 

9 

3K     " 

16 

31^     " 

6 

9y,   •■ 

21 

1 

416 


Shortening  absent  or  not  stated  in 584 

Abscess  not  present  in 105 


33^ 


ORTHOPEDIC  SURGERY 


Treatment. — The  principles  that  should  govern  the  treatment 
of  a  disease  are  best  indicated  by  the  study  of  cases  that  have 
received  no  treatment,  and  that  show,  therefore,  the  natural 
history  of  the  affection. 

A  characteristic  case  of  tuberculous  disease  of  the  hip-joint 
begins  insidiously.  It  causes  a  slight  limp  and  at  times  discom- 
fort and  pain.  In  the  early  stage  of  the  disease  there  is  a  slight 
flexion  of  the  limb,  usually  combined  wdth  abduction,  the  instinc- 
tive assumption  of  the  attitude  of  rest.  As  the  disease  progresses 
the  limb  becomes  less  capable  of  performing  its  proper  function; 
the  range  of  painless  motion  becomes  more  and  more  restricted, 
and  the  attitude  changes  to  one  of  increased  flexion  and  adduction, 
the  attitude  in  which  the  limb  is  best  protected  from  injury  and 
in  which  it  is  least  capable  of  performing  its  share  of  normal 
work.  Pain  is  more  constant,  abscess  is  often  present,  and  the 
constitutional  effects  of  a  depressing  disease  may  be  apparent. 
This  progression  of  symptoms  and  attitudes  is  so  fairly  constant 
that  hip  disease  was  in  former  times  often  divided  into  stages  corre- 
sponding to  these  early  and  later  manifestations  of  its  effects. 
When  the  limb  has  reached  the  position  of  greatest  protection, 
when  motion  which  at  first  was  limited  only  by  the  involuntary 
spasm  of  the  muscles  that  are  now  atrophied,  is  restricted  by 
adhesions  and  contractions,  pain  often  ceases  to  be  a  trouble- 
some symptom,  the  general  health  improves,  and  effective  repair 
begins.  During  the  progressive  stage  erosion  of  the  opposing 
surfaces  of  the  joint  has  advanced,  always  more  rapidly  at  the 
points  of  mutual  pressure  and  friction,  the  upper  and  inner  sur- 
face of  the  head  of  the  femur  and  the  upper  margin  of  the  acetabu- 
lum, and  here  the  disease  remains  active  while  repair  progresses 
at  the  points  which  have  been  relieved  from  irritation.  Thus 
in  many  instances  the  upper  margin  of  the  acetabulum  is  de- 
stroyed and  a  subluxation  of  the  femur  takes  place  (Fig.  198),  a 
displacement  favored  by  the  attitude  of  flexion  and  adduction, 
and  induced  by  muscular  spasm  and  by  pressure  upon  the  limb. 
In  some  instances  there  is  complete  displacement,  and  when  the 
diseased  parts  are  thus  separated  from  one  another  by  this  form 
of  pathological  dislocation  relief  of  symptoms  and  practical  re- 
covery may  quickly  follow,  although  sinuses  leading  to  areas 
of  local  disease  or  to  fragments  of  necrosed  bone  may  persist  for 
many  years. 

Nature's  cure  of  hip  disease  implies  recovery  with  a  shortened 
and  distorted  limb,  a  final  result  which  is  common  enough  even 


TUBERCULOUS  DISEASE  OF-THE  HIP-JOINT  333 

when  treatment  has  been  employed  to  explain  the  popular  con- 
ception of  what  hip  disease  entails  (Fig.  207). 

As  has  been  stated,  it  was  customary  in  former  years,  when 
treatment  was  neglected  or  less  efficient  than  at  the  present  time, 
to  speak  of  a  first,  second,  and  third  stage  of  hip  disease,  corre- 
sponding to  the  character  of  the  deformity,  but  early  or  later 
stage  as  used  by  the  writer  refers  to  the  inception  and  progression 
of  the  local  pathological  process,  not  to  the  distortion  of  the  limb. 

There  are  many  cases  of  hip  disease  in  which  the  primary  focus 
in  the  head  of  the  bone  is  so  limited  in  extent  that  perfect  func- 
tional cure  may  result  under  any  form  of  treatment,  or  non-treat- 
ment even.  And  there  are  others  in  which  the  disease  is  of  such 
a  destructive  character  that  the  result  must  be  disastrous  in  spite 
of  treatment.  But  there  can  be  no  doubt  that  by  early  diagnosis 
and  by  efficient  protection  prolonged  suffering  may  be  prevented, 
that  useful  function  may  be  preserved,  which  would  otherwise 
have  been  lost. 

The  object  of  treatment  is  to  prevent  the  symptoms  and  the 
effects  of  the  disease  that  have  been  outlined  as  characteristic  of 
the  untreated  cases.  To  relieve  the  pain  that  depresses  the 
vitality  of  the  patient.  To  relieve  the  muscular  spasm  that 
induces  distortion  of  the  limb,  and  that  stimulates  the  activity 
of  the  destructive  process  by  increasing  the  pressure  and  friction 
of  the  diseased  surfaces  of  the  opposing  bones.  To  correct  and 
to  prevent  deformity  and  to  prevent,  as  far  as  may  be  by  lessen- 
ing the  pressure  and  by  restraining  motion,  the  upward  dis- 
placement of  the  femur  that  causes  irremediable  distortion. 

There  are  cases  in  which  radical  removal  of  the  diseased  parts 
may  be  indicated,  and  there  are  times  when  acute  sjnmptoms  may 
require  absolute  rest  of  the  patient.  But  in  the  management  of 
a  chronic  tuberculous  disease,  throughout  the  period  of  years  that 
may  elapse  before  cure  is  accomplished,  the  primary  require- 
ments of  the  treatment  that  have  been  indicated  must  be  met,  as 
far  as  may  be,  by  appliances  that  allow  exercise  in  the  open  air. 

Mechanical  Treatment. — The  most  effective  treatment  of  a  dis- 
eased joint  is  that  which  assures  it  the  most  perfect  rest  and  pro- 
tection. If  the  disease  is  in  the  earliest  stage  and  confined  to  the 
interior  of  the  bone,  rest  offers  the  most  favorable  condition  for 
repair  and  for  preservation  of  the  joint.  If  the  disease  is  fur- 
ther advanced,  complete  relief  of  function  affords  an  opportunity 
for  nature  to  check  its  progress  and  to  preserve,  it  may  be,  a 
part  of  the  joint  from  invasion.     If  the  joint  is  already  involved, 


334  ORTHOPEDIC  SURGERY 

rest  offers  the  best  opportunity  for  repair  by  preventing  friction 
that  stimuhites  the  progress  of  the  disease  and  increases  its  de- 
structive effects.  ^Miatever  checks  or  retards  the  progress  of 
the  disease  correspondingly  relieves  its  s^nrnptoms  and  prevents 
constitutional  depression  and  thus  preserves  the  \dtal  resistance, 
both  local  and  general,  upon  which  the  cure  of  the  disease  ulti- 
mately depends.  Rest  of  a  diseased  joint  of  the  lower  extremity 
necessitates  splinting,  stilting  and  traction. 

Splixting  naturally  signifies  the  fixation  that  may  be  attained 
by  the  application  of  a  splint,  extending  a  sufficient  distance  on 
either  side  of  the  part  to  be  fixed. 

Stilting — the  elevation  of  the  foot  from  the  ground  so  that 
jar  and  pressure  on  the  diseased  articulation  may  be  removed. 

Teaction — a  sufficient  force  exerted  upon  the  limb  to  over- 
come and  to  control  the  spasmodic  action  of  the  muscles. 

The  knee-joint,  the  junction  of  two  levers  of  similar  size  and 
function,  may  be  easily  controlled  or  placed  at  rest  by  means  of 
apparatus.  But  the  hip-joint  is  a  ball  and  socket  joint  which 
allows  free  motion  in  many  directions,  and,  being  the  junction  of 
the  body  and  the  limb,  two  segments  of  different  size  and  func- 
tion, it  is  especially  difficult  to  control.  For  this  reason  as  much 
as  any  other,  perhaps,  the  treatment  of  hip  disease  has  been 
the  subject  of  controversy  for  many  years.  And  even  at  the  pre- 
sent time  one  can  hardly  describe  the  treatment  of  hip  disease 
adequately  without  contrasting  the  methods  of  treatment  that 
are  in  common  use. 

Such  an  exposition  should  begin  naturally  with  a  description 
of  what  has  long  been  known  as  the  American  treatment,  in 
which  traction  has  always  occupied  the  most  important  place. 

The  Traction  Hip  Splint. — The  traction  hip  splint  consists  of  a 
pelvic  band  and  an  upriglit.  The  pelvic  band  is  made  of  sheet 
steel  about  an  eighth  of  an  inch  in  thickness  and  one  and  one- 
eighth  inches  in  width,  sufficiently  strong  to  support  the  weight 
of  the  body  without  yielding,  bent  into  a  U-shape  to  conform  to 
the  pelvis,  but  wide  enough  to  cause  no  anteroposterior  pressure. 
As  Taylor  puts  it,  there  should  be  room  enough  for  the  pelvis  to 
move  freely  in  it.  This  band  embraces  about  three-quarters  of 
the  pelvis  at  a  point  just  above  the  trochanter.  It  is  covered 
with  leather,  and  is  provided  with  a  strap  to  complete  the  cir- 
cumference. Upon  the  pelvic  band  four  buckles  are  placed 
for  the  attachment  of  the  perineal  bands.  The  two  buckles  on  the 
front  band  are  placed  directly  above  the  attachments  of  the  ad- 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOIAT 


335 


ductor  muscles,  on  either  side  of  the  genitals.  Behind,  the  buckles 
are  placed  much  farther  apart,  somewhat  to  the  outer  side  of 
each  ischial  tuberosity,  upon  which,  in  great  part,  the  weight 
of  the  body  is  to  be  supported.  The  pehac  band  is  bolted  firmly 
to  the  upright  at  a  slight  inclination,  corresponding  to  the  inclina- 
tion of  the  pelvis.  The  upright  extends  from  the  top  of  the  tro- 
chanter to  two  or  more  inches  below  the  sole  of  the  foot.  It  may 
be  made  in  one  piece  or  in  two  sections  overlapped  and  attached 


Fig.  212 


Fig.  213 


Fig.  214 


The  traction  hip  splint,  with  overlapping  upright  and.  windlass,  used  at  the  Boston 
Children's  Hospital.      (Bradford  and  Lovett.) 

to  one  another  by  screws,  to  allow  for  adjustment  (Fig.  213). 
It  is  turned  inward  at  a  right  angle  below  the  foot  and  is  shod 
with  leather  or  rubber.  The  foot-piece  may  be  provided  with 
a  windlass  (Fig.  212),  or  the  traction  may  be  made  by  simple 
straps  attached  on  either  side  (Fig.  218).  At  about  the  middle 
of  the  upright  is  placed  a  support  of  light  steel,  which  is  provided 
with  a  broad  leather  strap  for  the  purpose  of  fixing  the  thigh  to 
the  brace  and  supporting  the  knee.  In  some  braces  a  second 
similar  support  is  j)laced  at  the  upper  part  of  the  stem;  in  others 


336  ORTHOPEDIC  SURGERY 

the  knee  is  supported  only  by  a  broad  leather  pad  which  covers 
its  inner  surface  and  is  attached  to  a  cross-piece  on  the  upright 
by  straps,  as  in  the  Taylor  brace.  In  the  Taylor  brace,  which 
has  served  as  a  model  for  all  similar  appliances,  the  upright  is  a 
steel  tube  into  which  slides  a  rod,  supporting  the  foot  part  of  the 
brace,  the  two  parts  being  joined  with  a  rack-and-pinion  attach- 
ment and  lock,  so  that  the  brace  may  be  lengthened  or  shortened 
by  means  of  a  key  (Fig.  217). 

Traction  Plasters. — Traction  upon  the  limb  is  made  by  adhesive 
plaster,  preferably  that  known  as  moleskin  (yellow)  plaster,  which 
is  far  less  irritating  to  the  skin  than  rubber  plaster. 

These  plasters  should  be  cut  into  a  shape  corresponding  to  the 
lateral  aspect  of  the  thigh  and  leg,  thus:  mde  above  and  narrow 
below,  reaching  from  the  trochanter  on  the  outer,  and  from  the 
pubes  on  the  inner  side,  to  the  malleoli  (Fig.  238).  The  lower 
ends  are  reinforced  by  a  second  layer  of  plaster  and  to  them 
buckles  are  attached.  The  plasters  are  then  applied  to  the  limb 
and  are  held  in  place  by  a  bandage  which  is  smoothly  applied 
and  then  sewed,  to  prevent  disarrangement.  The  object  of  the 
bandage  is  primarily  to  assure  the  adhesion  of  the  plaster  and 
secondarily  to  keep  it  clean.  It  can  be  replaced  by  a  properly 
fitted  covering  of  stockinette  or  by  a  stocking  leg. 

Another  method  of  applying  the  plaster,  designed  to  obtain 
a  better  hold  upon  the  limb,  is  that  devised  by  Taylor,  and  de- 
scribed by  him  as  follows:  "The  first  important  object  is  to 
seize  the  leg  in  such  a  manner  as  to  exert  against  it  an  unyielding 
force.  This  should  be  done  in  such  a  manner  as  will  not  interfere 
with  the  circulation,  nor  injure  the  knee,  by  unequal  strain  either 
below  or  above  it.  In  other  words,  the  whole  leg  should  be  grasped 
in  such  a  manner  that  the  knee  will  be  supported.  It  may  be 
done  as  follows :  A  strip  of  adhesive  plaster,  long  enough  to  reach 
from  the  waist  to  the  foot,  and  from  three  to  five  inches  wide  at 
the  upper  and  about  one-third  that  width  at  the  lower  end,  is  taken 
and  cut  into  five  tails,  as  shown  in  the  accompanying  illustration 
(Fig.  215).  A  piece  from  four  to  six  inches  long  is  cut  from  the 
centre  tail  and  added  to  the  lower  end  to  strengthen  it;  and,  if 
the  patient  be  strong,  one  or  two  more  pieces  are  laid  on  the  same 
place,  where  a  buckle  is  attached.  Two  similar  straps  are  pre- 
pared, one  for  the  inside  and  one  for  the  outside  of  the  leg,  and 
laid  against  the  lateral  aspects  of  the  leg,  the  ends  with  the  buckles 
beginning  about  two  inches  above  the  internal  and  external  mal- 
leoli, and  the  centre  tails  reaching  the  entire  length  of  the  leg 


TUBERCULOUS  DISEASE   OF  THE  HIP-JOINT  337 


and  thigh,  to  the  perineum  inside  and  the  trochanter  on  the  outside. 
The  lower  strips  or  tails  are  then  wound  spirally  around  the  leg 
to  the  pelvis  and  afterward  the  other  two  pairs  of  tails,  which  are 
cut  down  to  just  above  the  knee,  are  also  wound  about  the  thigh 
in  the  same  manner.  When  completed  the  thigh  is  involved  in 
a  network  of  strips  of  adhesive  plaster,  which  act  equally  and 
without  pressure  on  the  whole  surface.     The  leg  has  about  one- 


FiQ.  215 


FiQ.  216 


C.  F.  Taylor's  method  of  applying  adhesive  plaster. 

fourth  of  the  attachments,  and  the  thigh  three-fourths,  which  is 
found  to  be  the  right  proportion  to  protect  the  knee  equally  from 
compression  or  strain.  A  few  turns  of  the  roller  bandage  are 
then  made  around  the  ankle  just  under  the  lower  ends  of  the  straps, 
which  serves  as  a  protection  to  the  flesh  under  the  buckles,  and 
then  it  is  continued  over  the  straps  on  the  whole  leg.  Thus 
prepared,  the  patient  is  ready  for  the  splint"  (Fig.  216). 

At  the  Boston  Children's  Hospital  the  lower  ends  of  the  ad- 
hesive straps  terminate  in  tapes  that  extend  below  the  foot  for 

22 


338 


ORTHOPEDIC  SURGERY 


Fig.  217 


attachment  to  the  windlass,  which  is  used  with  the  cheaper  form 
of  brace. 

Perineal  Bands. — Perineal  bands  are  made  by  covering  a  firm, 
wide,  im^delding  band  of  webbing  with  several  folds  of  blanket 
or  similar  material  and  then  binding  it  smootlily  with  canton 

flannel.  These  axe  made  in  different 
lengths  and  sizes,  as  may  be  required. 
The  "High  Shoe."— The  best  and 
lightest  material  for  raising  the  shoe 
worn  on  the  sound  foot  to  corres- 
pond with  the  brace  is  cork,  and  the 
ordinary  thickness  is  two  and  a  half 
inches.  A  good  and  cheap  substitute 
may  be  made  of  light  wood  provided 
with  a  leather  sole,  and  in  certain 
cases  a  patten  of  metal  may  be  used. 
The  Application  of  the  Traction  Hip 
Splint. — The  traction  brace  is  ap- 
plied in  the  following  manner* 

The  patient  lying  upon  his  back, 
the  pelvic  band  is  first  adjusted  and 
is  strapped  about  the  body.  The 
perineal  supports  are  then  drawn 
firmly  into  place  so  that  pressure  on 
the  upright  does  not  move  the  pelvic 
band  from  its  proper  position,  just 
above  the  trochanter.  The  brace  is 
then  pushed  upward  against  the  re- 
sistance of  the  perineal  bands,  while 
the  limb  is  at  the  same  time  drawn 
downward  and  is  fixed  by  attaching 
the  straps  to  the  buckles  at  the  ends 
of  the  adhesive  plasters.  If  the  brace 
is  provided  with  a  windlass  or  ratchet,  further  traction  is  applied 
to  the  point  of  tolerance  by  means  of  the  key,  care  being  taken  in 
adjusting  the  brace  that  it  does  not  project  so  far  below  the  foot  as 
to  more  than  equal  the  extra  length  provided  by  the  high  shoe  on 
the  sound  side.  The  knee  band  is  then  adjusted  and  in  many 
instances  a  strap  is  placed  about  the  ankle  and  the  brace  to  assure 
greater  security.  The  shoe  is  then  put  on,  the  leg  clothing  is 
drawn  over  the  brace,  and  the  patient  is  allowed  to  stand.  If  in 
walking  the  patient  is  inclined  to  tilt  the  foot  downward  and  to 


The  original  traction  hip  brace  pro- 
vided with  an  abduction  screw  and  a 
strap  to  regulate  the  inclination  of 
the  pelvic  band  on  the  upright. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


339 


bear  the  weight  on  the  toe,  a  strap  is  attached  to  the  middle  of 
the  foot-piece  and  fastened  to  a  buckle  on  the  heel  of  the  shoe 
with  sufficient  tension  to  hold  the  foot  in  the  horizontal  position. 
By  means  of  this  brace  the  weight  is  borne  entirely  upon  the 
perineal  bands;  thus  the  joint  is  relieved  from  pressure  and  from 
The  perineal  bands  should  be  accurately  adjusted  to  pass 


lar 


upward  in  front,  parallel  to  one  another  on  either  side  of  the 


c 


A 


The  JudsoQ  brace.     This  has  but  one  perineal  band,  and  the  upright  is  bolted  firmly 
to  the  pelvic  band. 

genitals,  in  order  to  avoid  pressure  on  the  inner  borders  of  the 
thigh;  while  behind  they  turn  diagonally  outward  in  order  to 
pass  over  the  tuberosities,  which  are  best  adapted  for  weight 
bearing. 

In  the  original  Taylor  hip  brace  the  pelvic  band  is  bolted  to 
the  upright  in  a  manner  to  allow  anteroposterior  motion,  and  the 
inclination  of  the  pelvic  band  is  regulated  by  a  strap  attached 


340  OBTHOPEDIC  SURGERY 

to  the  upright  for  better  adjustment  (Fig.  217),  when  the  Hmb 
is  flexed  to  a  marked  degree.  This  brace  has  been  modified  by 
Taylor  by  shortening  and  changing  the  shape  of  the  pelvic  band 
for  the  use  of  but  one  perineal  support  (Fig.  252);  and  a  similar 
form  of  brace  is  used  by  Judson.  The  shortened  pelvic  band 
lessens  the  restraint  of  the  brace  upon  the  motion  of  the  limb, 
and  seems  to  offer  little  compensating  advantage. 

Before  the  traction  brace  is  used  in  ambulatory  treatment, 
distortion  of  the  limb,  if  it  be  present,  should  be  reduced ;  or  if  the 
disease  is  particularly  acute,  preliminary  rest  in  bed  until  the 
subsidence  of  the  symptoms  is  advisable. 

The  Reduction  of  Deformity  by  Means  of  the  Traction  Brace. — The 
patient  lies  in  bed  upon  a  firm  mattress;  the  distorted  limb  is 
then  raised  to  slightly  more  than  a  sufficient  angle  to  relax  the 

Fig.  219 


The  reduction  of  flexion  by  means  of  the  traction  hip  splint.     (C.  F.  Taylor.) 

contracted  muscles  and  to  straighten  the  lumbar  lordosis;  it  is 
then  abducted  or  adducted  if  necessary  until  the  level  of  the 
pelvis  is  restored.  The  pelvic  band  is  made  to  conform  to  this 
greater  relative  inclination  of  the  pelvis  by  lengthening  the  pos- 
terior strap;  the  brace  is  then  applied,  the  limb  being  held  in 
the  attitude  of  deformity  by  a  sling  or  support  (Fig.  219),  and 
as  much  traction  as  the  patient  can  tolerate  is  exerted  by  length- 
ening the  upright.  The  direct  traction  exerted  by  the  brace  may 
be  reinforced  by  means  of  a  cord  running  over  a  pulley  at  the 
foot  of  the  bed,  in  the  line  of  the  brace,  to  which  a  weight  of  ten 
or  more  pounds  (Fig.  220)  is  attached.  Thus  the  pressure  of 
the  perineal  bands  is  somewhat  lessened.  Efficient  traction  will 
quickly  reduce  recent  deformity  caused  by  muscular  contraction, 
and  as  this  is  lessened  the  position  of  the  limb  is  correspondingly 
changed  until  it  lies  extended  and  parallel  with  its  fellow.     If 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         34I 

adduction  be  combined  with  flexion  the  perineal  band  on  the 
side  opposite  to  the  disease  is  tightened  from  time  to  time,  or  a 
direct  push  against  the  opposite  adductor  region  is  exerted*  by 
means  of  a  bar  attached  to  the  brace  opposite  the  knee  (Fig. 
248).  In  ordinary  cases  the  deformity  may  be  reduced  by  this 
means  in  from  two  to  six  weeks. 

The  brace  should  be  worn  day  and  night.  The  perineal  bands 
may  be  loosened  at  times  to  allow  for  bathing  the  skin  with  alcohol 
and  for  powdering,  in  order  that  the  skin  may  be  kept  dry;  but 
at  such  times,  if  the  disease  be  acute,  manual  traction  should  be 
made  until  the  brace  has  been  readjusted.  The  adhesive  plasters, 
if  of  moleskin,  may  often  remain  in  position  for  three  months 
or  longer.  When  they  are  removed  the  limb  is  gently  bathed 
with   alcohol.     Excoriations   are   unusual    unless   rubber   plaster 

r  .1  r^  Fig.   220 


A  method  of  reducing  flexion  in  hip  disease.  The  brace  is  adjusted  to  the  angle  of  de- 
formitYi  and  in  addition  to  the  direct  traction  of  the  apparatus  weights  are  attached  to  the 
brace  itself.  In  the  illustration  counter-traction,  by  means  of  perineal  bands  attached  to 
the  head  of  the  bed,  is  shown. 

is  used.  If  the  skin  is  abraded  the  part  should  be  powdered 
with  boracic  acid  and  protected  from  the  plaster  by  a  layer  of 
gauze. 

The  Relative  Efficiency  of  the  Traction  Hip  Splint. — 
In  analyzing  the  action  of  this  brace  it  is  evident  at  once  that  it 
is  thoroughly  effective  as  a  stilt.  It  is  effective  as  a  traction 
appliance,  in  the  sense  of  relieving  muscular  tension,  in  direct 
proportion  to  the  care  that  is  exercised  in  its  adjustment.  Trac- 
tion by  this  appliance  may  be  made  constant  and  effective,  even 
to  the  point  of  practical  fixation  while  the  patient  is  in  bed,  or 
when  crutches  are  used,  in  ambulatory  treatment.  But  when 
the  apparatus  is  used  as  a  walking  brace,  as  was  designed  by  its 
inventor,  constant  traction  is  not  exerted,  for  the  traction  straps 
alternately  relax  and  tighten  when  the  weight  of  the  body  falls 


342  ORTHOPEDIC  SURGERY 

upon  and  leaves  the  brace  in  walking.  AVhen  the  brace  is  off 
the  ground  the  joint  is  subjected  to  the  traction  that  the  brace 
exerts,  plus  its  weight,  as  contrasted  with  cessation  of  traction 
and  the  relief  from  the  weight  when  the  brace  supports  the  body 
at  the  alternate  step.  Thus  the  critics  of  the  brace  assert,  in 
somewhat  exaggerated  language,  that  it  exercises  a  pumping 
action  on  the  joint.  As  a  matter  of  fact,  the  observation  of  patients 
under  treatment  by  this  method  will  show  that  little  actual  trac- 
tion is  exerted  in  the  ordinary  cases;  that  the  so-called  traction 
really  serves  principally  for  the  adjustment  of  the  brace,  which 
by  its  weight  exercises  a  certain  intermittent  traction  during 
locomotion.  The  hold  of  the  encircling  band  upon  the  pelvis 
assures  a  considerable  restriction  of  motion;  but  whatever  splint- 
ing action  it  may  have  depends  upon  the  degree  of  traction,  which 
is  never  effective  enough,  however,  to  prevent  a  certain  amount 
of  motion;  according  to  the  experiments  of  Lovett,  a  range  of  at 
least  35  degrees  even  when  the  brace  is  properly  adjusted.^ 

The  fact  must  be  borne  in  mind  that  the  traction  hip  splint 
was  not  intended  to  be  a  fixation  or  splinting  appliance.  On  the 
contrary,  Davis,  its  inventor;  Taylor,  who  changed  it  into  a  practi- 
cable form,  and  Sayre,  who  further  modified  it,  each  believed 
that  motion,  except  when  the  joint  was  fixed  by  muscular  spasm, 
was  desirable,  and  the  brace  was  designed  to  permit  it,  the  trac- 
tion preventing  friction. 

Motion  without  friction  in  this  sense  would  seem  to  imply  the 
actual  separation  of  the  femur  from  the  acetabulum,  or  distrac- 
tion as  distinct  from  traction.  That  actual  distraction  is  pos- 
sible at  the  hip-joint  both  in  health  and  disease  is  proved  by 
the  experiments  of  Brackett^  and  by  those  of  Bradford  and 
Lovett.  These  experiments  show  that  a  traction  force  from  ten 
to  twenty  pounds  is  required  to  cause  one-eighth  to  one-quarter 
of  an  inch  of  actual  lengthening  of  the  limb,  even  in  childhood. 
It  is,  therefore,  to  say  the  least,  imlikely  that  the  feeble  and  inter- 
nn'ttent  traction  exerted  by  a  hip  splint,  when  used  as  an  ambu- 
latory support,  can  be  sufficient  to  separate  the  bones  from  one 
another  and  thus  fo  allow  motion  without  friction  as  was 
originally  claimed  for  this  apparatus. 

At  the  present  time  the  theory  that  motion  of  a  joint  which  is 
actually  diseaserl  is  of  benefit,  or  even  that  it  is  harmless,  has 

1  R.  W.  Lovett,  New  York  Medical  Journal,  August  8,  1891. 

*  Brackett,  TransactionH    American    Orthopedic    AHHociatioii,    vol.     ii.     Bradford    and 
Lovett,  New  York  Medical  Journal,  August  4,  1804. 


TUBERCULOUS  DISEASE   OF  THE  HIP-JOINT         343 

few  supporters  even  among  those  who  use  the  traction  brace 
exclusively.  On  the  contrary,  the  motion  that  cannot  be  prevented 
is  excused  because  of  the  practical  efficiency  of  the  brace  and 
because  it  is  believed  that  no  more  effective  protection  can  be 
attained  by  any  other  method  of  ambulatory  treatment. 

In  all  acute  cases  a  period  of  rest  in  bed  with  traction  to  the 
point  of  actual  distraction  is  advised.  When  ambulation  is 
resumed  the  braced  limb  is  made  pendent  by  means  of  the  high 
shoe  and  crutches,  so  that  uninterrupted  traction  may  still  be 
exerted,  and  the  brace  is  only  used  as  a  supporting  appliance 
when  the  symptoms  indicate  that  the  disease  is  quiescent. 

As  has  been  stated,  treatment  by  the  long  traction  brace,  by 
means  of  which  motion  without  friction  was  at  one  time  claimed 
to  be  possible,  and  in  which  traction  is  the  distinctive  feature,  is 
sometimes  called  "The  American  Treatment  of  Hip  Disease." 
In  this  sense  the  direct  splinting  of  the  joint  without  traction,  by 
means  of  the  Thomas  brace,  might  be  called  in  distinction  "The 
English  Treatment." 

The  Thomas  Treatment  of  Hip  Disease. — H.  O.  Thomas,^  of 
Liverpool,  writing  at  a  time  when  in  America  it  was  generally 
believed  that  motion  was  essential  to  the  well-being  of  a  diseased 
joint,  and  when  fixation  was  supposed  to  predispose  to,  or  to 
actually  induce,  anchylosis,  states  "that  continuity  of  exten- 
sion per  se  is  not  a  remedy  in  hip-joint  disease;  in  its  appli- 
cation it  involves  unavoidably  a  fractional  degree  of  fixation 
which  is  sufficient  to  mask  the  evil  of  this  ridiculous  mal- 
practice." 

The  conclusions  on  which  his  treatment  is  founded  are  these: 
"The  main  obstacle  to  the  cure  of  an  inflamed  joint  is  the  friction 
and  pressure  of  its  surfaces;  consequently  the  attainment  of  rest, 
that  is  of  immobility  of  the  articulation,  ought  to  be  the  principle 
which  should  guide  the  treatment.  Pressure  and  concussion  are 
less  to  be  feared  than  friction.  Effectual  rest  can  only  be  ob- 
tained by  mechanical  treatment,  and  for  this  purpose  the  appli- 
ances which  I  here  recommend  are  effectual.  The  more  an 
inflamed  joint  is  moved  the  stiffer  does  it  become;  while  the  more 
effectually  it  is  fixed,  the  sooner  and  the  more  completely  is  its 
capability  of  movement  restored.  To  ensure  permanency  of 
cure  the  control  should  be  maintained  for  a  period  beyond  the 
time  when  resolution  has  taken  place.     This  prolonged  arrest  of 

1  Diseases  of  the  Hip,  Knee,  and  Ankle-Joints  Treated  by  a  New  and  Effective  Method, 
1875.  p.  10. 


344 


ORTHOPEDIC  SURGERY 


a  joint's  movements,  for  even  an  unnecessarily  long  period,  I 
have  never  found  to  do  harm." 

The  splint  used  by  Mr.  Thomas  to  carry  out  these  principles 
effectively  is  described  by  him  substantially  as  follows: 

A  flat  piece  of  malleable  iron,  three-quarters  of  an  inch  wide 
and  three-sixteenths  of  an  inch  thick  for  children,  and  one  inch 
by  one-quarter  inch  for  adults,  long  enough  to  extend  from  the 
lower  angle  of  the  scapula  to  the  middle  of  the  calf,  forms  the 


Fig.  221 


Fig.  222 


The  splint  in  its  sim- 
plest form,  not  yet  pad- 
ded or  covered.  (Rid- 
lon.) 


The  Thomas  hip  splint,  covered  and  fitted  with  shoulder  straps. 
(Ridlon  and  Jones.) 


upright.  This  is  fitted  to  the  body  of  the  patient, 
passing  from  the  lower  angle  of  the  scapula,  in 
a  perpendicular  line,  downward,  over  the  lumbar 
region,  across  the  pelvis,  slightly  external,  but 
close  to  the  posterior  spinous  process  of  the  ilium 
and  the  prominence  of  the  buttock,  along  the 
course  of  the  sciatic  nerve  to  a  point  slightly  ex- 
ternal to  the  calf  of  the  leg.  It  must  be  care- 
fully modelled  to  this  track.  The  lumbar  por- 
tion of  the  upright  must  be  invariably  almost  a  plane  surface,  but 
it  must  be  twisted  slightly  on  its  long  axis  at  the  junction  of  the 
upper  and  middle  third,  so  that  the  anterior  surface  of  the  lower 
part  may  look  slightly  outward  to  correspond  to  the  contour  of 
the  buttock  and  thigh.  A  second  and  double  bend  is  made  in 
the  upright  at  the  point  where  it  passes  the  buttock,  so  that  the 
thigh  part  lies  on  a  slightly  higher  plane  than  the  body  part,  but 
parallel  with  it.  The  upright  is  then  provided  with  chest,  thigh, 
and  leg  bands  (Fig.  221). 

The  chest  band  is  of  hoop  iron,  one  and  a  half  inches  in  width 
by  one-eighth  of  an  inch  in  thickness.  This  is  bent  into  an  oval 
to  correspond  with  the  shape  of  the  chest,  being  four  inches  less 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


345 


than  the  circumference  at  this  point  if  the  patient  is  an  adult, 
and  of  a  corresponding  size  for  a  child.  It  is  riveted  to  the  upper 
extremity  of  the  brace,  so  that  one-third  of  its  length  shall  be  on 
the  side  corresponding  to  the  diseased  joint  and  two-thirds  on  the 
other.  The  thigh  band  and  leg  band  are  of  similar  material, 
three-quarters  by  one-eighth  of  an  inch  in  size.  The  thigh  band, 
in  length  equal  to  two-thirds  of  the  circumference  of  the  thigh, 
is  fastened  to  the  upright  at  a  point  one  to  two  inches  below  the 
buttock,  and  the  calf  band,  equal  in  length  to  half  the  circum- 
ference of  the  leg  at  the  calf,  is  riveted  to  the  lower  extremity  of 
the  brace.     Both  the  thigh  and  leg  bands  are  attached  to  the 


Fig.  223 


Method  of  changing  the  line  of  pressure  on  the  skin  from  the  Thomas  hip  splint  by 
drawing  the  tissues  to  one  side.     (Ridlon  and  Jones.) 

brace  at  points  slightly  to  the  inner  side  of  the  centre,  so  that  the 
outer  arm  of  each  band  is  somewhat  longer  than  the  inner.  The 
brace  is  padded  with  thin  boiler  felt  and  is  covered  smoothly  with 
basil  leather.  In  fitting  the  brace  to  the  patient  the  long  part  of 
the  chest  band  should  be  made  to  hug  the  body  closely,  while 
the  short  arm  should  be  somewhat  away  from  it.  The  anterior 
surface  of  the  thigh  part  of  the  upright  should  have  a  perceptible 
outward  t^vist  and  should  be  somewhat  on  tlie  inner  side  of  the 
popliteal  space.  Thus  the  instrument  is  prevented  from  rota- 
ting outward  and  becoming  a  side  splint.     The  chest  band  is 


346  ORTHOPEDIC  SURGERY 

closed  with  a  strap  and  buckle;  it  is  suspended  by  shoulder  straps, 
and  the  leg  between  the  two  bands  is  attached  to  the  brace  by 
means  of  a  flannel  bandage.  Ridlon  states  that  in  practice  this 
bandage  is  usually  replaced  by  a  strip  of  basil  leather  passed 
across  the  front  of  the  limb  close  do\\Ti  to  the  upper  border  of 
the  patella,  thence  backward  and  downward  to  the  stem  of  the 
splint  and  pinned  to  the  covering,  so  that  the  resistance  to  the 
do\^Tiward  working  of  the  brace  is  borne  by  the  quadriceps  femoris 
muscle.  The  ordinary  shoulder  straps  may  be  replaced  by  a 
single  bandage  looped  about  the  upper  part  of  the  stem  (Fig.  223) . 
This  bandage  is  twisted  for  a  length  of  about  six  inches,  then 
separated,  the  ends  being  carried  over  the  shoulders,  are  passed 
through  holes  in  the  corresponding  ends  of  the  chest  band,  where 
they  are  knotted,  and  finally  the  two  ends  are  tied  to  one  another, 
completing  the  circumference  of  the  chest  band. 

This  brace  is  fitted  by  the  surgeon  directly  to  the  patient's 
body  as  he  stands  erect.  If  the  limb  is  already  flexed  the  foot 
is  raised  by  blocks  until  the  lumbar  lordosis  is  straightened;  the 
brace  is  then  bent  to  fit  the  angle  of  deformity  and  is  applied  in 
the  usual  manner. 

The  brace  is  made  of  iron  because  it  is  less  elastic  than  steel, 
and  because  it  can  be  more  easily  twisted  by  wrenches.  It  must 
be  heavy  and  strong  in  order  to  splint  the  part  effectively,  and 
it  can  only  be  an  effective  splint  when  it  is  fixed  in  its  proper 
position  and  exercises  direct  pressure  upon  the  hip-joint.  In 
cases  in  which  the  brace  has  been  properly  adjusted  a  deep 
furrow  should  appear  in  the  buttock  directly  over  the  neck  of  the 
femur.  Once  fitted  to  the  patient  it  is  changed  only  at  infrequent 
intervals  and  always  by  the  surgeon,  who  is  particularly  careful 
not  to  move  the  limb  during  the  active  stage  of  the  disease. 

The  double  Thomas  hip  splint  is  made  by  joining  two  single 
splints.  These  are  riveted  to  the  chest  band  above  and  are  con- 
nected at  the  lower  ends  by  a  crossbar  unless  the  brace  is  to  be 
used  in  the  reduction  of  deformity.  Care  must  be  taken  that 
the  uprights  pass  to  the  outer  side  and  not  directly  over  the  poste- 
rior superior  spines  of  the  ilium. 

The  Reduction  of  Deformity  by  the  Thomas  Method. — Preferably 
in  the  treatment  of  children  the  double  brace  is  applied,  the  sound 
limb  being  fixed  in  the  extended  position  while  the  flexed  limb  is 
supported  by  the  other  arm  of  the  brace,  bent  to  the  angle  of 
deformity.  The  patient  is  confined  to  the  bed  and,  as  the  mus- 
cular spasm  relaxes  under  the  influence  of  enforced  rest,  the  brace 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


347 


is  straightened  slightly  by  wrenches  from  time  to  time,  at  a  point 
opposite  the  joint,  to  conform  to  the  improved  position  until 
symmetry  is  restored.  In  resistant  cases  this  gradual  relaxation  is 
hastened  by  straightening  the  brace  somewhat  at  intervals,  to 
which  the  attached  limb  must  conform — a  gradual  forcible  reduc- 
tion of  deformity.  According  to  Ridlon  and  Jones,  the  flexed 
limb  is  often  forced  to  conform  to  the  straight  brace  by  a  tem- 
porary exaggeration  of  the  lumbar  lordo  is  which  lessens  as  the 
spasm  subsides  under' treatment. 


Thomas  splint  applied  with  patten  and  crutches. 

The  treatment  is  di\ided  by  Mr,  Thomas  into  stages: 

1.  A  preliminary  stage  of  rest  in  bed  for  the  reduction  of 
deformity  and  to  allow  for  subsidence  of  acute  symptoms. 

2.  The  patient  is  then  allowed  to  go  about  on  crutches  wearing 
an  iron  patten  at  least  four  inches  in  height  under  the  sound 
foot  (Fig.  224). 

3.  When  all  symptoms  of  disease  have  subsided  and  when  atrophy 
of  the  muscles  is  marked  the  brace  may  be  removed  at  night. 


348 


ORTHOPEDIC  SURGERY 


4.  The  brace  is  finally  discarded,  but  the  patten  and  crutches 
are  still  used  in  walking. 

According  to  Ridlon^  the  records  of  Mr.  Thomas  show  the 
average  time  of  confinement  to  the  bed  to  be  twenty-two  weeks, 
and  the  average  duration  of  treatment  twenty-one  months. 

It  is  stated  by  Ridlon^  that  in  actual  practice  tliese  principles 
were  not  carried  out,  for  nearly  all  the  children  treated  under 
Thomas'  direction  at  the  time  his  observations  were  made  were 
walking  about  without  the  high  patten  and  crutches,  even  before 
the  deformity  had  been  overcome  and  while  muscular  spasm  and 
pain  persisted. 

This  was,  however,  probably  an  exigency  of  practice  among 
the  poor,  and  at  all  events  it  is  in  line  with  Thomas'  contention 
that  pressure  and  concussions  are  less  harmful  than  friction. 


Fig.  225 


A  form  of  Thomas  brace  employed  in  the  treatment  of  infants.  The  pelvic  band  assures 
better  fixation.  The  screws  at  the  lower  extremity  are  arranged  to  permit  the  addition  of 
a  foot-piece  for  traction. 

Modifications  of  the  Thomas  Brace. — Although  not  so  stated  in 
his  book,  Thomas  used  at  times  a  short  brace  extending  only  to 
the  lower  part  of  the  thigh,  thus  permitting  motion  at  the  knee. 
This  was  apparently  designed  as  a  convalescent  splint,  although 
its  use  was  not  restricted  to  that  class  of  cases.  In  certain  cases 
a  strip  of  iron,  "the  nurse,"  was  screwed  to  the  lower  extremity 
of  the  long  brace,  prolonging  it  beyond  the  foot  in  order  to  pre- 
vent the  patient  from  bearing  weight  upon  the  limb. 

The  Thomas  brace,  so  effective  in  preventing  and  overcoming 
flexion  deformity,  does  not  prevent  lateral  distortion.  In  fact, 
in  twenty-four  of  the  fifty-eight  patients  examined  by  Ridlon," 
adduction  was  present;  a  larger  proportion,  it  would  appear, 
than  would  be  found  in  a  like  number  of  cases  under  treatment 


'  Transaction.s  American  Orthopedic  Association,  vol.  i.  p.  17. 

*  A  report  of  Sixty-two  Cases  of  Hip  Disease  Observed  in  the  Practice  of  Hugh  Owen 
Thomas,  New  York  Medical  Journal,  October  4,  1890. 

*  Loc.  cit. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         349 

with  the  traction  brace.  This  tendency  to  lateral  distortion  may 
be  guarded  against  by  placing  a  half  band  of  material  similar  to 
the  chest  band  about  the  side  of  the  pelvis;  on  the  same  side 
for  adduction,  on  the  opposite  side  for  abduction  of  the  limb. 

The  Thomas  brace  has  a  great  advantage  over  other  appliances 
in  its  simplicity.  It  can  be  made  by  a  blacksmith,  but  it  must 
be  fitted  by  the  surgeon.  This  fitting  requires  great  care.  In 
the  words  of  Mr.  Thomas:  "The  fitting  although  sometimes 
successful  in  one  visit,  may  at  other  times  occupy  many  days. 
The  surgeon  should  mould,  by  reducing  or  increasing  the  various 
curves,  until  the  instrument  ceases  to  tend  to  rotate,  and  at  none 
of  its  angles  irritates  the  patient."  He  concludes,  in  a  general 
answer  to  the  criticisms  that  have  always  been  made  on  the  diffi- 
culty of  adjustment  of  the  appliance,  as  follows:  "What  I  can 
invariably  do  must  be  possible  to  others." 

Treatment  by  the  Plaster  Bandage. — A  third  routine  method  of 
treatment  is  that  by  means  of  the  plaster  bandage  without  crutches 
or  high  shoe.  This  is  simple  splinting  with  whatever  protection 
from  concussion  the  support  may  assure. 

This  treatment  might  be  called  the  German  method  if  the 
'  traction  hip  splint  and  the  Thomas  brace  are  to  be  designated  as 
American  and  English. 

As  used  in  the  surgical  clinic  at  Berlin,  the  plaster  bandage  is 
applied  from  the  line  of  the  nipples  to  include  the  foot,  the  limb 
being  fixed  in  an  attitude  of  slight  flexion,  abduction,  and  out- 
ward rotation.  As  a  rule,  the  first  bandage  is  applied  under 
anaesthesia  for  the  purpose  of  relaxing  the  muscular  contraction 
and  facilitating  the  application.  If  nutritive  shortening  of  the 
muscles  is  present,  suflScient  force  is  employed  to  overcome  the 
deformity.  The  spica  is  renewed  at  intervals  of  from  two  to  four 
months.  When  the  disease  is  cured  and  after  the  bandage  is 
finally  removed  traction  at  night  is  employed  for  a  time  by  means 
of  a  weight  attached  to  the  foot  to  prevent  tlie  tendency  to  dis- 
tortion. In  ambulatory  treatment  this  method  has  little  to  recom- 
mend it  except  expediency,  but  as  a  temporary  support  to  be  used 
before  the  application  of  a  suitable  brace  the  plaster  spica  is  most 
useful. 

When  properly  applied  it  is  an  admirable  support,  often  far  more 
comfortable  to  the  patient  than  any  brace,  and  it  is  at  times  an 
indispensable  form  of  dressing.  It  has  the  same  defects  as  the 
plaster  jacket,  and  it  may  receive  the  same  defence  that  its  most 
severe  critics  have  had  tlie  least  experience  in  its  use. 


350  ORTHOPEDIC  SURGERY 

Application  of  the  Long  Plaster  Spica  Bandage.— A  plaster 
ba^dage  to  assure  support  should  fit  perfectly,  consequently  it 
should  be  applied  as  closely  as  is  possible.  A  close-fitting  covering 
of  shirting,  such  as  is  used  in  the  application  of  the  plaster  jacket, 
is  dra\\-n  on  and  is  covered  with  one  or  more   layers    of   cotton 

Fig.  226 


The  long  plaster  spica  bandage.     The  dotted  line  indicates  the  position  of  the 
steel  support. 

flannel  bandage,  those  parts  that  are  likely  to  be  subjected  to  pres- 
sure— the  toes,  the  heel,  the  malleoli,  the  condyles  of  tlie  femur,  the 
sides  of  the  pelvis,  the  anterior  superior  spines,  and  the  thorax — 
being  suitably  protected  by  cotton  wadding  or  other  material.  The 
plaster  bandage  should  cover  the  lower  half  of  the  thorax,  and  it 


TUBERCULOUS  DISEASE  OF  THE  HIP- JO  INT 


351 


should  extend  to  the  ends  of  the  toes.  It  should  be  applied  under 
slight  traction^  very  carefully  around  tlie  adductor  region  and  the . 
buttock,  which  should  be  entirely  covered  and  supported.  At 
this  point,  in  the  line  in  which  the  bar  of  the  Thomas  hip  splint 
runs,  a  piece  of  splint  wood  or  a  strip  of  malleable  steel,  long 
enough  to  reach  from  the  middle  of  the  trunk  to  the  lower  third 
of  the  thigh,  should  be  incorporated  in  the  plaster  (Fig.  224). 
A  similar  piece  is  sometimes  placed  in  front  of  the  hip  and  another 
beneath  the  knee,  the  points  at  which  the  bandage  is  likely  to 
break.  Tlie  proper  anteroposterior  support  of  the  buttock,  con- 
sequently of  the  hip-joint,  which  is  of  the  firet  importance,  is 
almost  invariably  neglected  in  the  ordinary  application.  Tiie 
bandage  may  be  applied  in  the  upright  posture  by  means  of 
the  swing,  as  used  in  the   application  of  the  plaster  jacket,  the 


Fig.  227 


Box  with  adjustable  sacral  support  used  for  the  apphcation  of  plaster  spica  bandage. 


weight  being  supported  in  part  by  the  sound  leg  while  the  other 
is  pendent.  Usually  it  is  applied  with  the  patient  in  the  reclining 
posture,  the  body  being  supported  by  a  shoulder  rest,  and  the 
pelvis  by  a  sacral  support.  The  arms  are  tlien  drawn  above  tlie 
head  to  increase  the  capacity  of  the  thorax,  while  the  limbs  are 
supported  by  an  assistant  (Figs.  227  and  230). 

In  the  more  recent  cases,  deformity  may  be  practically  reduced 
at  the  second  application  of  the  bandage,  because  of  the  relaxation 
of  the  spasm  assured  by  the  rest  and  fixation;  thus  it  is  particu- 
larly useful  in  the  treatment  of  young  children  in  the  outdoor 
practice,  for  whom  hospital  care  would  othen\ase  be  required. 

The  Short  or  Lorenz  Spica  Bandage. — The  short  spica 
bandage  is  used  as  routine  treatment  of  hip  disease  in  Lorenz's 
clinic  in  Vienna  unless  direct  weiglit  bearing  causes  pain.  It  is 
applied  in  the  manner  described  under  tlie  treatment  of  congenital 


352 


OBTHOPEDIC  SURGERY 


dislocation  of  the  hip,  tlie  aim  being  to  fix  the  affected  limb  in 
an  attitude  of  slight  flexion  and  abduction,  tlie  primary  attitude 
of  hip  disease.  A  close-fitting  covering  of  shirting  is  drawn  over 
the  limb  and  pehas,  and  a  wide  bandage  is  then  introduced  be- 


FiG.  228 


The  Lorenz  spica,  showing  the  adjustment  to  the  pelvis.     In  this  case  it  is  extended  below 
the  knee,  but  in  many  instances  motion  at  the  knee-joint  is  permitted. 

tween  the  skin  and  shirting  to  serve  as  a  "scratcher."  The  bony 
prominences  are  suitably  protected  by  cotton  or  sheet  wadding,  and 
the  bandages  are  then  applied,  being  drawn  closely  and  carefully 
moulded  about  the  pelvis  and  tliigli,  so  that  movement  in  the  joint 
may  be  controlled.    The  upper  and  lower  extremities  of  the  bandage 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         353 


Fig.  229 


are  cut  away  as  illustrated  (Fig.  228),  and  the  shirting  is  then  drawn 
over  the  margins  of  the  plaster  and  sewed.  This  makes  a  smooth 
covering  and  holds  the  padding  in  position.  If  tlie  bandage  is  ex- 
tended below  the  knee  it  is  more  efficient.  As  an  adjunct  to 
mechanical  support  and  during  the  stage  of  recovery,  or  even  in 
the  treatment  of  cases  of  a  mild  type,  the  bandage  is  very  satis- 
factory, but  as  a  routine  treatment  it  is  not  a  sufficient  protection. 
It  should  be  stated  that  in  the  treatment  of  the  more  acute  cases 
by  Lorenz  the  weight  of  the  body  is  removed  by  a  prolongation 
or  stirrup  of  sheet  steel  which  projects  beyond  the  foot,  the  two 
extremities  being  incorporated  in  either  side  of  the  plaster  bandage 
in  the  neighborhood  of  the  knee  (Fig.  229).  In 
the  better  class  of  cases  a  leather  support  pro- 
vided with  a  steel  foot-plate  extending  slightly 
below  the  foot  and  a  joint  at  the  knee  is  used. 
The  short  spica  bandage  in  combination  with  the 
traction  hip  brace  (Fig.  237)  answers  the  same 
purpose  and  is  more  efficient  if  somewhat  more 
cumbersome. 

Immediate  Reduction  of  Deformity. — In  the  more 
resistant  cases  an  anaesthetic  may  be  administered. 
If  the  deformity  is  due  simply  to  muscular  spasm 
the  limb  may  be  placed  in  the  proper  position 
without  force;  but  if,  as  is  often  the  case  when 
the  distortion  is  of  long  standing,  it  is  caused  in 
part  by  shortening  of  the  muscles  and  fasciae,  a 
certain  amount  of  force  may  be  required. 

The  pelvis  should  be  fixed  and  the  force 
should  be  applied  as  far  as  possible  by  direct  trac- 
tion rather  than  by  leverage.  Subcutaneous  di\d- 
sion  of  the  contracted  tissues  about  the  anterior 
superior  spine  and  in  the  adductor  region  may  be 
required.  In  very  resistant  cases  the  reduction 
of  deformity  by  this  method  should  be  di\ided  into  several  oper- 
ations. Lorenz  reduces  the  adduction  deformity  by  means  of  a 
machine  that  exercises  direct  traction  on  the  adducted  limb  while 
the  sound  limb  is  pushed  upward,  so  that  practically  no  leverage 
is  exerted  on  tlie  joint. ^ 

In  cases  in  which  the  deformity  is  accompanied  by  abscess,  or 
when  the  joint  is  surrounded  by  infiltrated  tissues  and  by  sinuses, 
this  treatment  should  not  be  employed.     In  fact,  in  certain  cases 


The  Lorenz  stilt, 
sometimes  used  in 
the  treatment  of  the 
more  painful  cases. 
This  is  incorporated 
in  the  plaster  band- 
age above  the  knee 
and  it  extends  below 
the  foot. 


>  Lorenz,   Sammluog  klin.  Vor.,  206,  Leipzig,  March,  1898. 
23 


354 


ORTHOPEDIC  SURGERY 


of  this  class,  especially  Avhen  subluxation  is  present,  it  is  often 
ad\-isable  to  disregard  tlie  deformity  tliat  cannot  be  reduced  by 
traction  until  the  disease  is  cured,  when  it  may  be  overcome  by 
osteotomy  of  the  femur. 

The  immediate  reduction  of  deformity,  properly  performed,  is 
free  from  danger;  and  it  has  become  almost  the  routine  of  prac- 
tice in  the  indoor  department  of  the  Hospital  for  Ruptured  and 
Crippled.  The  great  advantage  of  placing  the  hmb  in  the  proper 
position  and  fixing  it  for  weeks  or  months,  combined  with  trac- 


FiG.  230 


A  pelvic  supp(jrt  in  u.se.     Tlie  palioMt  prcsciit.s  fixed  flexion  to  135  degrees,  and  fixed 
adduction  of  35  degrees. 

tion,  if  this  seems  advisable,  instead  of  employing  this  time  for  the 
gradual  reduction  of  the  deformity,  is,  of  course,  self-evident. 
Three  methods  of  reduction  of  deformity  have  been  described: 

1.  By  means  of  the  traction  brace. 

2.  By  means  of  the  Thomas  brace. 

3.  By  means  of  the  plaster  bandage,  witli   or  without  anaes- 
thesia. 

A  fourth  method  is  that  by  means  of  the  weiglit  and  pulley. 
This  is  in  conmion  use  because  it  ref|uircs  no  specnal  aj)])a,ratus. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT 


355 


Reduction  of  Deformity  by  the  Weight  and  Pulley. — 
The  traction  plasters  are  applied  to  the  limb  in  the  manner 
already  described,  and  the  patient  is  placed  on  his  back  on  a 
narrow,  firm  mattress.  The  limb  is  raised  until  the  lumbar  vertebrje 
rest  upon  the  bed  and  it  is  then  moved  to  one  or  the  other  side, 
if  lateral  distortion  is  present,  until  the  level  of  the  pelvis  is 
restored.     In  this  position  the  limb  is  supported  on  a  pillow,  or 

Fig.  231 


I 


w 


Weight  extension  acting  as  leverage  in  hip  disease.  P,  pulley;  W,  weight;  F,  fulcrum. 
Marsh's  diagrams,  illustrating  the  advantage  of  traction  in  the  line  of  deformity,  in  order 
to  avoid  leverage.     (Howard  Marsh., 

better,  on  the  adjustable  triangle  used  with  the  traction  hip  splint 
(Fig.  219).  A  pulley  is  then  attached  to  the  foot  of  the  bed  in 
a  prolongation  of  the  line  of  the  flexed  limb.  The  wheel  may 
be  screwed  to  the  top  of  a  narrow  board,  which  may  be  raised 
or  lowered  on  the  foot  of  the  bed  as  required.  To  the  buckles  on 
the  plaster  traction  straps,  a  stirrup  carrying  the  cord  is  attached 
This  stirrup  is  simply  a  spreader  of  narrow  thin  wood,  slightly 
wider  than  the  foot,  provided  at  either  end  with  straps  or  tapes, 

Fig.  232 


Posture  of  the  limb  in  hip  disease  in  which  extension  should  be  applied  in  order  to 
avoid  leverage.     P,  pulley;  W,  weight;  F,  fulcrum. 

its  purpose  being  to  prevent  direct  pressure  on  the  malleoli  (Fig. 
234).  By  means  of  a  weight  suspended  at  the  foot  of  the  bed 
traction  is  made  upon  the  limb  to  the  extent  that  the  comfort 
of  the  patient  will  permit.  As  in  Buck's  system  of  traction, 
the  foot  of  the  bed  is  raised  to  increase  the  friction  of  the  body 
and  thus  to  counteract  the  traction  force,  but  in  the  treatment 
of  children  this  is  inefficient  and  countertraction  must  be  provided. 
A  simple  method  is  to  attach  two  perineal  bands,  as  described 
in  connection  Avith  the  traction  brace,  to  strong  tapes  that  pass 


356 


ORTHOPEDIC  )SURGERY 


above  and  below  the  patient's  body,  to  be  fixed  to  the  head  of 
the  bed  at  a  suitable  distance  from  one  another;  thus  the  pelvis 
is  supported  by  prolonged  perineal  bands. 

In  order  to  assure  efficient  and  constant  traction  the  patient  must 
be  prevented  from  sitting  up.  For  this  purpose  a  swathe  about  the 
body  or  shoulder  straps  may  be  applied  and  attached  to  the  bed. 

A  convenient  appliance  is  that  of  Marsh:  "This  consists  of 
a  piece  of  webbing,  passing  across  the  front  of  the  chest  and 
ending  in  two  loops,  through  which  the  two  arms  are  passed, 
and  through  which  is  threaded  another  piece  of  stout  webbing 
wliich  runs  transvei-sely  across  the  surface  of  the  bed  under  the 
child's  shoulders,  and  is  fastened  at  its  two  ends  to  the  sides  of 
the  bedstead.  ^Vhen  this  is  in  action  the  patient's  shoulders 
are  kept  flat  on  the  bed,  so  that  he  can  neither  sit  up  nor  turn 


Fig.  233 


Extension  in  hip  disease.     Marsh's  method  of  fixing  the  patient  in  bed  with  shoulder 
straps  and  a  long  T-splint  on  the  sound  side.     (Howard  Marsh.) 

on  his  side.  This  chest  band  does  not  cause  the  slightest  dis- 
comfort. It  Ls  not,  of  course,  fixed  tightly,  and  when  the  child 
finds  that  he  cannot  sit  up  he  makes  no  further  attempt  to  do 
so;  and  as  he  lies  flat  the  band  is  loose." 

It  is  often  of  advantage,  particularly  if  the  disease  is  active, 
to  use  some  form  of  apparatus  to  fix  the  patient  more  thoroughly. 
Marsh  uses  a  long  lateral  splint  of  thin  board  reaching  from  the 
axilla  to  a  crossbar  below  the  sole  of  the  foot.  To  this  the  pa- 
tient's body  and  sound  limb  are  bandaged  (Fig.  233). 

For  the  same  purpose  a  plaster  spica  bandage  or  a  Thomas 
splint  may  be  applied  on  the  sound  side,  but  a  more  convenient 
appliance  is  the  frame  of  gas-pipe  covered  with  canvas  that  has 
been  described  in  the  chapter  on  Pott's  disease.  Upon  this  frame 
the  patient  can  be  fixed,  the  limb  being  elevated  by  a  support 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


357 


attached  to  the  frame  or  independent  of  it  (Figs.  234  and  235). 
It  is  perhaps  needless  to  suggest  that  the  bedclothes  must  be  held 
from  the  elevated  limb;  in  fact,  that  the  patient  must  for  a  time 


Fig.  234 


Traction  by  means  of  weight  and  pulley.     (R.  T.  Taylor.) 
Fig.  235 


Method  of  fixing  the  patient  to  the  Bradford  frame  for  traction  in  hip  disease. 
(R.  T.  Taylor.) 

be  enclosed  in  a  tent  of  bedclothes  if  the  deformity  is  extreme. 
At  first  the  traction  weight  must  not  be  great,  but  as  the  peri- 
neum^becomes  accustomed  to  pressure  as  much  weight  as  can  be 


353  OR THOPEDIC  S UBGEB  Y 

tolerated  is  used,  from  ten  to  twenty  pounds  being  the  average. 
This  may  be  reduced  at  night  and  increased  durmg  the  day. 
Great  care  must  be  taken  to  prevent  painful  pressure  on  the 
perineum  by  careful  adjustment  and  frequent  inspection  ot  the 

perineal  bands. 

If  the  frame  is  used  it  may  be  provided  with  a  windlass  at 
the  bottom  for  traction  and  Ts^th  an  arched  band  of  metal  across 
the  pelvis  for  the  attachment  of  the  perineal  bands,  which  behind 
are  fastened  to  the  side  bars  at  a  higher  level.  Thus  the  frame 
mav  be  made  an  independent  recumbent  splint  on  which  the 
patient  mav  be  moved  about.  If,  however,  one  desires  to  exert 
traction  to  the  point  of  distraction,  the  weight  and  pulley  arrange- 


Fig.  236 


Lateral  and  longitudinal  traction  in  hii.  lUsease.     (Page.) 

ment  Is  more  satisfactory;  in  this  case  the  limb  should  be  placed 
in  an  attitude  of  slight  flexion  and  abduction,  so  that  the  temur 
may  be  drawn  more  directly  from  the  acetabulum. 

Lateral  Traction.— Thus  far  longitudinal  traction  has  been  con- 
sidered, but  lateral  traction  or  traction  in  the  line  of  the  neck  ot 
the  femur  deserves  some  consideration. 

Mr  Thomas,  who  condemned  all  forms  of  traction  as  deceptive 
and  irrational,  and  especially  longitudinal  traction,  speaks  thus 
of  lateral  traction:  "For  surely  if  relief  from  pressure  be  re- 
quired, the  only  direction  in  which  this  is  possible  is  clearly  m 
the  axis  of  the  neck  of  the  femur.  Any  method  of  extension  in 
the  axis  of  the  body  merely  transfers  the  pressure  from  the  upper 
part  of  the  acetabulum  to  the  lower  quarter."^    This  contention 


•  Loc.  cit.,  p.  10. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  359 

is  purely  theoretical,  as  there  is  no  evidence  to  show  that  injurious 
pressure  is  ever  exerted  upon  this  part  of  the  acetabulum.  On 
the  contrary,  the  specimens  from  subjects  who  have  been  treated 
by  longitudinal  traction  in  recumbency  and  by  means  of  the  trac- 
tion hip  splint  almost  invariably  show  the  effect  of  pressure  upon 
the  upper  part  of  the  head  of  the  femur  and  upon  the  upper  ad- 
joining margin  of  the  acetabulum.  Moreover,  the  neck  of  the 
femur  is  in  childhood  so  short  and  is  set  upon  the  shaft  at  so 
great  an  angle  that  longitudinal  traction,  if  the  limb  is  slightly 
abducted,  is,  practically  speaking,  in  the  line  of  the  neck;  so  that 
even  from  the  theoretical  standpoint  the  question  of  injurious 
pressure  could  only  arise  in  the  treatment  of  adults.  The  advan- 
tage of  lateral  traction  in  the  treatment  of  hip  disease  was  urged 
by  Phelps^  as  early  as  1889,  and  it  has  been  applied  as  a  routine 
practice  in  ambulatory  treatment  by  Blanchard,^  of  Chicago, 
since  1872. 

The  effect  of  lateral  traction  in  recumbency  has  been  carefully 
investigated  by  C.  G.  Page.^  His  conclusions  are  that  lateral 
traction  alone  is  of  no  benefit,  but  if  applied,  together  with  longi- 
tudinal traction,  it  gives  great  relief  in  certain  acute  cases.  The 
longitudinal  traction  should  be  twice  as  great  as  the  lateral,  ten 
and  five  pounds  being  the  average  weights  employed  in  his  ex- 
periments.    The  method  is  shown  in  the  illustration  (Fig.  219). 

The  Relative  Efficiency  of  Traction  and  Splinting 
("Fixation"). 

In  considering  the  vexed  question  of  the  relative  merits  t)f 
splinting  and  traction  in  preventing  muscular  spasm  and  the  con- 
sequent intra-articular  pressure  which  cause  pain  and  increase 
the  destructive  effects  of  the  disease,  these  facts  must  be  borne 
in  mind. 

The  more  acute  tlie  disease  the  less  ability  of  the  joint  to 
carry  out  its  proper  function,  which  is  motion.  The  greater  the 
motion  under  these  circumstances  the  more  intense  the  muscu- 
lar spasm,  of  which  the  object  is  the  prevention  of  motion.  If  it 
were  possible,  therefore,  to  fix  the  joint  absolutely  there  should  be 
no  muscular  spasm,  although  the  tension  of  acute  disease  within 
the  bone,  or  of  its  products  within  the  joint,  might  cause  pain. 

1  New  York  Medical  Record,  May  4,  1889. 

-  Transactions  American  Orthopedic  Association,  vol.  \-\\. 

3  C.  G.  Page,  Boston  Medical  and  Surgical  Journal,  September  13,  1894. 


360  ORTHOPEDIC  SURGERY 

^'\Mien  the  patient  is  fixed  in  the  recumbent  posture  it  is  possible 
to  apply  a  sufiicient  traction  upon  the  muscles  to  prevent  the  spas- 
modic contraction  that  causes  injurious  pressure,  and  although 
no  amount  of  traction  vn\\  absolutely  prevent  motion,  yet  with 
the  support  that  the  bed  provides,  practically  speaking,  complete 
rest  may  be  assured.  Only  in  the  exceptional  cases  in  which 
tension  upon  congested  tissues  about  an  acutely  inflamed  joint 
is  intolerable  is  this  method  of  treatment  inefficient. 

The  same  statement  is  true  of  a  properly  applied  spica  bandage 
or  Thomas  brace,  when  the  patient  is  recumbent,  that  it  assures 
practical  rest;  thus  it  prevents  muscular  contraction,  relieves  the 
symptoms  and  promotes  repair,  although  it  cannot  be  claimed 
that  the  surfaces  of  the  opposing  bones  are  actually  separated 
from  one  another. 

But  what  is  true  when  the  patient  is  recumbent  is  not  true  in 
ambulatory  treatment.  The  traction  exerted  by  the  hip  splint, 
even  when  the  limb  is  pendent,  is  far  less  effective  than  in  recum- 
bency, and  when  it  is  used  as  a  walking  appliance,  for  which  it 
was  designed  and  for  which  it  is  practically  always  employed, 
the  traction  is  intermittent  and  of  doubtful  efficiency.  The  same 
loss  in  efficiency,  although  in  far  less  degree,  occurs  in  all  forms 
of  fixative  apparatus  when  used  in  ambulation;  but  it  may  be 
stated  without  reserve  that  splinting  is  of  far  more  importance 
in  actual  practice  than  is  traction. 

The  Removal  of  Direct  Pressure.  "Stilting." — Granting  that 
the  traction  brace  as  a  walking  appliance  is  relatively  inefficient 
in  preventing  motion,  and  that  motion  without  friction,  provided 
the  joint  surfaces  are  actually  involved,  is  impossible,  still  the 
traction  brace  is,  or  may  be,  at  all  times  an  effective  stilt  in  that 
it  protects  the  joint  from  concussion  and  pressure  by  removing 
the  foot  from  contact  with  the  ground. 

It  is  true  that  the  removal  of  direct  pressure  may  be  assured 
by  the  use  of  axillary  crutches,  but  in  Thomas'  practice  they 
were  used  in  but  few  cases.^  In  fact,  it  is  only  by  constant  super- 
vision that  the  use  of  crutches  can  be  enforced  upon  children  who 
no  longer  suffer  pain;  and  as  it  is  practically  impossible  to  pre- 
vent the  patient  from  bearing  weight  upon  the  limb,  stilting  by 
this  means  is  relatively  inefficient. 

That  direct  pressure  is  one  of  the  causes  of  upward  displace- 
ment of  the  femur  may  be  inferred  from  the  statistics  of  Sasse 

1  Ridlon,  loc.  cit. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         361 

and  Bruns/  from  the  surgical  clinics  of  Berlin  and  Tubingen, 
where  the  routine  of  treatment  is  the  plaster  bandage  without  the 
high  shoe  or  crutches.  In  two-thirds  of  Sasse's  and  in  four-fifths 
of  Bruns'  cases  there  was  upward  displacement  of  the  trochanter. 
This  is  certainly  a  larger  proportion  than  would  be  found  in  a 
corresponding  class  of  patients  treated  by  efficient  stilting,  although 
statistics  on  this  point  from  American  sources  are  lacking. 

The  Practical  Combination  of  Traction.  Splinting  and  Stilting. — 
Thus  far  the  methods  of  treatment  by  splinting  and  traction 
have  been  presented  as  if  they  were  opposed  to  one  another  in 
principle  as  indeed  they  are  in  practice.  For  in  this  country  the 
prevailing  treatment  is  still  the  traction  hip  splint;  in  England 
the  Thomas  hip  brace,  and  on  the  Continent  the  plaster  support. 

It  should  be  recognized,  however,  that  the  principle  involved 
in  each  method  is  the  same,  and  that  the  actual  merit  of  each 
must  be  decided  by  practical  experience  rather  than  by  argument. 
The  true  test  of  the  relative  value  of  a  routine  of  treatment  is  its 
efficacy  in  hospital  practice,  where  its  weak  points  cannot  be  sup- 
plemented by  the  careful  supervision  that  may  make  almost  any 
method  effective  that  carries  out  in  some  degree  the  proper  prin- 
ciple. This  test  is  all  the  more  necessary  because  the  great  major- 
ity of  cases  of  this  character  are  to  be  found  among  the  poor. 

From  this  point  of  view  the  writer's  experience  may  be  of 
interest.  His  early  training  was  entirely  in  the  traction  method, 
but  the  observation  of  a  large  number  of  cases  in  which  this  treat- 
ment was  used  led  to  the  following  conclusions: 

In  one  sense  the  treatment  was  successful,  in  that  it  in  great 
degree  relieved  the  symptoms  throughout  the  course  of  the  dis- 
ease and  enabled  the  patients  to  go  about  in  the  open  air,  to 
attend  to  school,  and  even  to  join  in  the  games  of  their  fellows. 
It  was  evident,  however,  from  an  inspection  of  the  patients  as 
they  returned  for  treatment,  that  the  relief  of  symptoms  was  due 
to  the  protection  ensured  by  the  stilting  or  crutch-like  action  of 
the  brace  and  not  by  traction,  which  was  usually  simply  traction 
in  name,  not  in  fact.  But  if  the  brace  relieved  the  s^-mptoms,  it 
did  not,  in  many  instances,  prevent  deformity;  and  as  the  preven- 
tion of  deformity  is  an  object  only  secondary  in  importance  to  the 
relief  of  pain,  the  treatment  was  in  so  far  unsatisfactory.  This 
deformity  was  usually  flexion,  occasionally  combined  with  adduc- 
tion, a  deformity  often  increasing  slowly  without  pain,  or  other 

1  Sasse,  Arbeit  aus  der  klin.  Chir.,  Berlin,  1896.     Bruns,  Archiv  f.    klin.    Chir  ,  Bd 
xlviii.,  H.  1. 


362 


ORTHOPEDIC  SURGERY 


evidence  of  greater  actmty  of  disease.  If  the  deformity  were 
reduced  by  traction  in  recumbency,  it  reappeared  when  ambu- 
latory treatment,  by  the  brace,  was  resumed.  This  flexion  seemed 
to  be  in  many  instances  simply  an  adaptation  to  the  prevailing 
postures.  "\Mien,  for  example,  the  patient  assumed  the  sitting 
position,  the  limb  was  flexed  in  spite  of  the  brace,  and  as  much 
of  the  time  was  passed  in  this  attitude,  its  influence  on  the  pro- 
duction of  deformity  seemed  to  be  obvious. 

The  most  accurate  statistics  of  final  results  in  cases  treated 
by  this  apparatus  illustrate  also  its  ineffectiveness  in  preventing 
deformity.  Thus  in  a  total  of  thirty-five  cases  treated  at  the  N.  Y. 
Orthopedic  Dispensary^  practical  anchylosis  was  present  in  74° 
and  in  60°  the  limb  was  distorted  to  a  greater  or  less  degree. 


Fic.   237 


^^^ 

^"■^^SmiT' 

l-« 

^T^^'^H 

^,:.  .. '  iiiifififii'giii  fiMiMHRBIIfli 

Vfe.    ^^P^ 

™^p^ 

kVl 

The  short  spica  bandage  reaching  to  the  knee  in  combination  with  the  brace.  One 
perineal  band  has  been  removed  in  order  to  show  how  the  joint  is  supported  by  the  band- 
age.    The  short  spica  of  the  Lorenz  model  may  be  used  also  for  this  purpose. 

It  was  also  apparent  that  the  brace  was  not  effective  in  relieving 
pain  during  the  more  acute  exacerbations,  even  during  recum- 
bency with  such  traction  as  could  be  applied  by  the  parents;  nor 
when  the  children  were  brought  in  arms  to  the  clinic. 

Under  these  conditions  it  was  found  that  acute  symptoms 
might  be  relieved,  or  greatly  modified,  almost  at  once,  by  the 
a[>plication  of  a  close-fitting  short  spica  bandage  extending  from 
the  middle  of  the  thorax  to  the  knee.  Over  this  the  brace  was 
applied  as  before,  making  an  apparatus  which  then  combined 
splinting,  traction,  and  stilting  (Fig.  237).  This  treatment  was 
r(!peated  in  many  instanc(;s,  always  with  tlu;  same  result.  As 
the  apj)licati()n  of  the  plastcT  bandage  was  a,  somewhat  tedious 


'  Shaffer  and  fjovett,  New  York  Medical  Journal,  March  2,  1878. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


363 


proceeding,  it  was  often  exchanged  for  a  short  Thomas  splint 
worn  beneath  the  pelvic  band  of  the  traction  brace  in  the  same 
manner.  The  fixation  appliance  not  only  relieved  pain  in  the 
acute  cases,  but  it  also  prevented  the  deformity,  which  was  not 
checked  by  the  traction  brace  alone. 

This  combination  of  the  short  Thomas  brace  and  the  traction 
hip  splint  was  effective  as  a  means  of  relieving  pain  and  preventing 
deformity.    It  had,  however,the 

disadvantage  of  requiring  care-  ^"^'  "^^ 

ful  adjustment,  and  it  obliged 
the  patient  to  wear  shoulder 
straps;  in  other  words,  much 
care  must  be  exercised  to  en- 
sure the  comfortable  adjust- 
ment of  both  appliances.  Thus 
the  next  step  was  the  combina- 
tion of  the  two,  even  though  the 
action  was  somewhat  less  effec- 
tive. To  the  pelvic  band  of  the 
traction  brace  a  lateral  thoracic 
bar  was  attached,  reaching  up- 
ward in  the  axillary  line  to  a 
point  opposite  the  middle  of  the 
scapula,  where  it  was  joined  to 
a  metal  band  that  encircled  the 
chest,  like  that  of  the  Phelps 
brace.  When  this  was  securely 
fastened  about  the  chest,  the 
body  and  the  limb  were  held  in 
line  by  a  long  lateral  brace ;  the 
pelvis  was  supported  by  the  pel- 
vic band  and  the  joint  received 
the  additional  protection  that 
was  assured  by  traction  and 
stilting  (Figs.  238  and  239). 

This  brace  is  now  in  general 
use  at  the  Hospital  for  Ruptured  and  Crippled.  Its  ejBBciency  may 
be  still  further  increased  by  replacing  the  perineal  bands  with  a 
metallic  ring.  'J'liis  ring,  which  fits  the  upper  extremity  of  thigh 
closely,  is  attached  to  the  upright  at  an  inclination  corresponding 
to  the  line  of  the  groin  (Fig.  240).  (The  Thomas  ring  is  descril^ed 
fully  in  connection  with  his  laiee  splint.)     It  is  a  better  support 


The  long,  inexpensive  brace,  with  solid  up- 
right, showing  the  perineal  bands  and  the  ad- 
hesi\'e  plaster,  as  used  in  hospital  practice. 


364 


ORTHOPEDIC  SURGERY 


because  it  prevents  anteroposterior  motion  within  the  pelvic  band, 
which  the  perineal  straps  allow.  The  ring  may  be  used  as  the 
only  support  or  it  may  be  combined  with  a  perineal  band  on  the 
opposite  side.  This  is  of  advantage  if  there  is  a  tendency  toward 
adduction. 

The  apparatus  is  most  satisfactory  when  the  hollow  upright  of 
the  Taylor  brace  is  used.  This  is  hglit  and  strong,  and  is  pro- 
\\ded  vdih  an  arrangement  for  effective  traction,  but  in  hospital 
practice  the  upright  is  made  of  solid  metal,  and  the  traction  is 
made  by  simple  straps.  The  metallic  ring,  besides  providing 
better  fixation,  is  a  firm  support  that  cannot  be  removed  by  the 
patient.  It  is,  of  course,  more  difficult  of  adjustment,  and  it  is 
not  suited  to  the  treatment  of  young  children  because  of  the  diffi- 
culty in  keeping  it  clean  and  dry. 

Fig.  239 


The  long  hip  splint  applied. 

The  Thomas  ring  was  first  applied  to  a  hip  splint  by  Phelps 
(Fig.  242).  He  urged  the  advantages  of  fixation  and  traction,  and 
his  brace,  of  which  that  last  described  is  simply  a  slight  modi- 
fication, is  provided  with  an  arrangement  for  lateral  traction. 
Practically  speaking,  this  is  a  tape  by  which  the  lower  third  of 
the  thigh  is  held  in  apposition  to  the  upright.  It  hardly  seems 
possible  that  appreciable  lateral  traction  can  be  exerted  on  the 
joint  by  this  means  if  the  metallic  ring  is  properly  fitted  to 
the  thigh.  The  simple  straps  do  not  afford  as  effective  traction 
as  the  rack  and  pinion,  nor  is  the  brace,  as  usually  constructed, 
sufficiently  strong  to  bear  the  weight  of  the  body  without  bend- 
ing. It  should  be  stated,  however,  that  this  form  of  brace  is 
intended  to  be  used  with  crutches  rather  than  as  a  walking  appli- 
ance. 

Certain  objections  to  this  attempt  to  combine  effective  splinting 
with  traction  and  stilting  have  been  urged  by  those  who  believe 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


365 


in  the  efficiency  of  the  ordinary  traction  brace.  For  example,  it  is 
said  that  the  splinting  is  ineffective  because  the  movements  of  the 
trunk  are  transmitted  to  the  joint,  while  this  is  not  true  of  braces 
that  do  not  extend  above  the  pelvis. 


Fia.  240 


Fig.  241 


The  long  brace,  with  Thomas'ring  andlex- 
tension  upright,  similar  to  Phelps'  brace. 


Rear  view  of  brace. 


As  a  matter  of  experience,  it  will  be  found  that  motion  of  the 
upper  part  of  the  trunk  is  absorbed,  as  it  were,  in  the  flexible 
lumbar  region  of  the  spine  before  it  reaches  the  joint.  If,  however, 
such  motion  or  any  motion  causes  discomfort  or  aggravates  the 


366 


ORTHOPEDIC  SURGERY 


s}Taptoms,  the  patient  should  be  confined  in  the  recumbent 
posture  until  the  acute  phase  of  the  disease  has  passed.  It  is  said 
that  the  brace  is  cumbersome,  that  the  patient  cannot  sit  with 
comfort,  and  that  it  prevents  normal  activity.  A  long  brace  cer- 
tainly weighs  more  than  a  short  one,  and  if  a  brace  prevents 
flexion  of  the. hip  and  spine  it  is  evident  that  tlie  patient  cannot 
sit  with  comfort  in  an  ordinarv  chair. 


Fig.  242 


Fig.   243 


The  I'help.s  hip  .splint. 


ATchair  to  be  used  with  the  l(jiig  hip  isi>liiit.  The 
patient  sits  upon  the  sound  side,  while  the  splinted 
half  of  the  body  remains  in  the  extended  position, 
the  brace  resting  on  the   floor. 


The  patients  themselves,  however,  make  little  complaint  of 
the  brace,  even  when  it  has  been  substituted,  for  an  ordinary 
traction  splint;  while  the  greater  restraint  of  activity  is  a  favor- 
able element  of  treatment,  since  children  who  do  not  suft'er  pain 
are  much  more  likely  to  be  too  active  than  to  be  harmfully  re- 
strained by  any  form  of  appliance.  These  objections  are  trivial 
if  one  is  convinced  that  the  dangerous  and  deforming  disease 
that  is  under  treatment  may  be  more  easily  controlled  and  that 
the  final  result  is  likely  to  be  better  and  to  be  more  rapidly  attained 
V)y  this  means  than   by  another. 


T  UBER CULOUS  DISEASE  OF  THE  HIP-JOIN T         367 


It  would  be  of  advantage,  of  course,  if  a  brace  could  be  so 
adjusted  to  the  pelvis  and  to  the  femur  as  to  fix  the  joint  without 
interfering  with  the  movements  of  the  spine.  Such  fixation  can 
be  attained  by  a  close-fitting  plaster  bandage  of  the  Lorenz 
model    (Fig.  228)    used  in    conjunction    with   traction   plasters. 


Fig.  244 


Fig.    24.5 


The  Lorenz  spica  combined  with  the  traction 
hip  brace.  The  perineal  strap  prevents  dis- 
placement of  the  plaster  appliance. 


Lateral  view.     The  shape  of  the  pelvic  bantl  is  like  thai 
illustrate!  in  Fig.  248. 


To  these  a  shoil  traction  hip  brace  of  the  Taylor  model,  as  shown 
in  Figs.  244  and  245  is  adjusted. 

It  will  be  noted  in  the  ilhistrations  that  the  limb  is  fixed  in  a 
moderate  degree  of  abduction.  This  attitude  is  indicated  because 
the  tendency  of  thv  disease  is  toward   adduction,  the  attitude  in 


368 


ORTHOPEDIC  SURGERY 


which  the  destructive  changes  in  the  joint  tliat  lead  to  upward 
displacement  of  the  trochanter  take  place.  Abduction  lessens 
the  pressure  also  of  the  articulating  surfaces  on  one  another,  and 
whatever  the  apphance  used  it  should  be  adjusted  to  favor  this 
attitude. 

It  may  be  noted  that  there  is  a  very  general  tendency  to  shorten 
the  period  of  stilting  and  to  permit  weight  bearing  when  it  no 
longer  causes  discomfort.  This  is  based  on  the  fact  that  complete 
cessation  of  function  for  long  periods  leads  to  extreme  atrophy 
of  the  limb,  to  relaxation  of  the  joints,  and  to  loss  of  growth. 
Even  if  early  weight  bearing  lessens  the  range  of  motion,  yet  the 
function  of  the  limb  is  ultimately  better  and  the  period  of  com- 
plete disability  shorter  than  under  the  brace  treatment  prolonged 
through  many  years. 

Perhaps  the  most  effective  treatment  of  a  case  of  hip  disease  of 
the  ordinary  type  is  immediate  reduction  of  deformity  under  anaes- 
thesia.    The  limb  to  which  traction  plasters  have  been  applied  is 


Fig.   246 


The  short  plaster  spica,  combined  with  traction  used  after  reduction  of  deformity. 

then  fixed  by  means  of  a  Lorenz  spica  bandage  in  an  attitude 
of  complete  extension  and  moderate  abduction  (Fig.  246).  A 
traction  weight  of  about  ten  pounds  is  applied,  and  is  con- 
tinued until  all  discomfort  has  ceased,  usually  for  several 
weeks. 

A  perineal  crutch  of  the  Taylor  model  is  then  applied  as  a  walk- 
ing apparatus  (Fig.  244).  By  this  means  one  assures  the  essentials 
of  protection,  and  the  prevention  of  deformity  without  including 
the  thorax  in  the  apparatus,  but  to  be  effective  the  plaster  spica 
must  be  renewed  as  soon  as  it  becomes  loose.  When  the  disease 
appears  to  be  quiescent  the  brace  is  tentatively  removed  to  allow 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


369 


the  patient  to  bear  weight  on  the  limb.  For  assuming  that  pres- 
sure without  movement  is  less  harmful  than  motion  without  pres- 
sure one  ma}-  restore  the  stimulation  of  the  weight  bearing  function 
and  yet  protect  the  part  more  effectively  than  by  the  ordinary  hip 
brace.     This  treatment,  although  the  most  satisfacory  in  practice, 


Fig.   247 


Fig.  248 


The  Lorenz  spica  illustrating  the  adjustment  to 
the  iJelvis  antl  the  perineal  band. 


The  Taylor  hip  splint  as  used  by 
Taylor  in  the  later  years  of  his  practice 
with  but  one  perineal  band.  The  illus- 
tration shows  also  an  appliance  for  pre- 
venting or  for  correcting  slight  degrees 
of  adduction,  while  the  brace  is  in  use 
as  a  walking  appliance.  The  abduction 
bar  is  buckled  about  the  upper  extrem- 
ity of  the  other  thigh.  (H.L.Taylor, 
Medical  News,  March  23,  1889.) 


requires,  however,  more  care  and  skill  in  adjustment  of  the  appli- 
ances than  the  methods  previously  described. 

The  impression  that  one  might  receive  from  descriptions  of  the 
treatment  of  hip  disease  is  that  most  cases  begin  acutely,  or  that 
when  the  patients  are  brought  for  treatment  the  disease  is  in  an 

24 


lO 


ORTHOPEDIC  SURGERY 


acute  stage,  or  that  deformity  is  present,  so  that  prehminary  re- 
cumbency is  required.  But  each  year  the  proportion  of  early 
cases  is  greater,  cases  in  which  there  is  no  deformity  and  in  which 
acute  s^inptoms  are  absent.     In   such   instances  the   hip  sphnt 


Fic.   249 


Taylor's  median  abduction  brace  used  as  a  bed  splint  to  overcome  adduction  by 
counterpresHure  upon  the  sound  side. 


or  plaster  spica  may  be  applied  without  preliminaiy  recumbency, 
and  if  the  joint  is  fixed  in  the  nonnal  attitude  and  protected  a 
relatively  rapid  recovery  without  deformity  and  witli  a  fair  range 
of  motion  may  })e  hoped  for. 


TUBERCULOUS  DISEASE  OF  THE  HTP- JOINT        371 

The  Treatment  of  Hip  Disease  during  the  Stage  of  Recovery. — It 
is  much  easier  to  assure  one's  self  that  the  disease  is  stiU  active 
than  to  decide  when  it  is  cured.  For  the  symptoms  may  have 
been  quiescent  for  months  or  years  even,  under  the  protective 
treatment,  and  yet  they  may  recur  on  the  shghtest  provocation 
when  this  treatment  has  been  discontinued. 


Fig.  250 


Fig.  251 


Fig.  250. — Modified  brace  to  be  worn 
during  convalescence.  Same  patient  as  in 
Fig.  241.  The  thoracic  part  has  been  re- 
moved and  the  lower  end  of  the  stem  has 
been  made  into  a  caliper,  passing  through  the 
heel  of  the  shoe.  The  stem  is  extended  by 
means  of  the  key  until  the  heel  is  lifted 
slightly  from  the  shoe  ;  thus  the  hip  is  re- 
lieved from  shock. 

Fici.  251. — Judson's  perineal  crutch.  This 
support  suspended  from  the  shoulders  may 
be  employed  as  a  substitute  for  axillary 
crutches.  It  is  also  used  as  a  convalescent 
splint  in  theltreatment  of  hip  disease. 


To  judge  of  the  probable  duration  of  the  disease  in  a  given 
case,  one  must  consider  its  area,  its  quality,  and  its  complica- 
tions. If,  for  example,  the  primary  s}Tiiptoms  indicate  that  the 
focus  of  infection  is  of  limited  area  and  is  contained  within  the 
bone,  rapid  recovery,  possibly  in  a  year,  may  be  expected;  but 


372 


ORTHOPEDIC  SURGERY 


fiG.   252 


in  the  ordinary  h-pe  of  disease  in  which  the  joint  has  been  in- 
vaded, repair  can  hardly  be  anticipated  in  less  than  three  or  four 
years.  Supposing  that  suflBcient  time  has  elapsed  to  permit 
of  natural  cure,  if  there  have  been  no  s}Tiiptoms  of  active  dis- 
ease for  a  year  or  more,  and  if 
muscular  spasm  is  absent,  one 
may  test  the  joint  by  removing 
the  brace  at  night  to  ascertain  the 
effect  of  simple  motion  without 
weight  bearing.  Such  freedom 
will  enable  the  patient  to  move 
the  knee,  which  having  been  fixed 
in  the  extended  position  for  so 
long  usually  remains  stiff  for  a 
time;  in  fact,  several  months  may 
elapse  before  the  full  range  of 
motion  is  regained. 


Fig.  253 


Convalescent  hip  splint,  allowing  motion  at  the  knee.      (Taylor.) 


It  is  well,  also,  to  remove  the  thoracic  part  of  the  brace  to  allow 
the  patient  more  mobility  at  the  hip.  At  a  later  time  the  traction 
may  be  discontinued  and  the  brace  may  be  suspended  from  the 
shoulders  to  serve  as  a  perineal  crutch  (Fig.  251);  or  it  may  be 
attached  to  the  shoe  and  so  adjusted  as  to  be  slightly  longer  than 
the  limb,  in  order  that  direct  concussion  and  pressure  may  be 
lessened  (Fig.  2.^>()j.  Or  a  brace  jointed  at  the  knee,  after  the 
Taylor  pattern,  may  ])e  employed. 


TUBERCULOUS  DISEASE  OF  THE  HIP- JOINT         373 


This  brace  is  so  adjusted  as  to  be  slightly  longer  than  the  limb, 
so  that  the  heel  does  not  touch  the  bottom  of  the  shoe  (Fig.  253). 
Thus  the  weight  is  in  great  part  supported  on  the  perineal  band. 
The  weight  of  the  brace  may  be  in  part  supported  and  incidentally 
slight  traction  may  be  exerted  by  adhesive  plaster  applied  above 


Fig.  254 


Fig.  255 


Fig.  256 


Details  of  the  Taylor  convalescent  hip  brace. 
Fig.  254,  the  adhesive  plaster.  Fig.  255,  the 
foot-plate  showing  the  method  of  attachment. 


.^f^ 


The  action  of  the  Taylor  convalescent 
hip  brace  in  removing  direct  pressure 
illustrated  by  wooden  model. 


the    knee  (Fig.  254).     The   foot-plate,  to  which    the  upright  is 
attached,  is  shown  in  Figs.  253  and  255. 

As  the  strain  upon  the  part  is  increased,  one  watches  carefully 
for  the  return  of  muscular  spasm  or  for  restriction  of  the  range 
of  motion.  If  the  range  of  motion  does  not  diminish,  and  if  the 
deformity  that  may  be  present  does  not  increase  or  does  not 


374 


ORTHOPEDIC  SURGERY 


appear  if  it  were  absent,  the  brace  may  be  removed  at  intervals 
and  finally  discarded. 

As  has  been  stated,  the  short  spica  after  the  Lorenz  model  is 
an  admirable  support  during  the  period  of  recovery.  It  prevents 
motion  at  the  joint,  yet  it  permits  the  function  of  support,  and 
thus  a  gradual  rebuilding  of  the  bonv  structure  which  has  become 
atrophied  during  the  course  of  the  disease.  By  means  of  this 
appliance  the  limb  may  be  held  in  the  desired  position  of  slight 
abduction,  and  it  is  particularly  effective  when  the  limb,  because 
of  destructive  changes  in  the  joint,  is  inclined  toward  adduction. 


Fu:.    257 


Double  hip   disease,   leniiiiuit  iiiK   i"   bcmy   ;uichyl(jsis. 


It  sluHiid  be  stated  that  the  long-continued  fixation  of  the  limb, 
especially  if  coml)ined  with  traction,  may  induce  laxity  of  the 
ligaments  and  hyperextension  at  the  knee,  unless  it  is  properly 
supported  by  the  posterior  tliigh  Ijand.  In  the  cases  in  which 
the  atrophy  is  extreme  and  in  which  this  laxity  is  present  the  splint 
may  be  (Jiscardcd  in  favor  of  the  fixation  bandage  with  advantage 
(Fig.  2.%). 

This  period  of  supervision  even  in  favorable  cases  should  be 
protracted,  for  no  j)ati('iit  can  be  considered  free  from  the  danger 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


375 


of  relapse  for  a  long  time  after  apparent  cure.  If  there  is  firm 
bony  union,  as  in  exceptional  cases,  cure  is  assured;  but  if 
there  is  simple  fibrous  anchylosis,  and  particularly  if  there  is 
upward  displacement  of  the  trochanter,  there  is  a  strong  tendency 
toward  flexion  and  adduction,  even  though  the  disease  is  cured. 
In  such  cases  it  is  often  necessary  to  employ  apparatus  at  intervals 
to  reduce  the  deformity  or  to  hold  the  limb  in  proper  position 
until  stability  is  assured.  \Vlien  the  brace  has  been  discarded, 
the  patient  should  be  trained  to  walk  with  equal  steps,  placing 


Fi< 


Hyperextensiiiii  at  the  knee  fnUowing  disease  of  the  hip-joint  and  its  ireatiiier.t 
liy  the  traction  brace. 

the  limb,  as  far  as  possible,  on  an  equality  with  its  fellow  and 
adapting  in  like  manner  the  stronger  to  the  weaker  member. 

This  has  an  important  influence  in  checldng  the  tendency  to 
deformity  and  in  modifying  or  even  concealing  the  limp,  a  point 
to  which  Judson  has  repeatedly  called  attention. 


Bilateral  Hip  Disease. 

Ninety-five  cases  of  bilateral  hip  disease  were  treated  in   the 

Hospital  for  Ruptured  and  Crippled  during  a  period  of  ten  y(>;irs 

As  a  rule,  the  second  hip  is  affected  some  time  after  the  synip- 


376  OR THOPEDIC  S URGER  Y 

toms  of  disease  of  tlie  first  have  been  apparent,  but  occasionally 
both  joints  are  involved  simultaneously.  In  most  instances  the 
s}Tnptoms  are  rather  subacute,  oAving,  very  likely,  to  the  fact 
that  the  actiA^ity  of  the  patient  is  so  restricted. 

Treatment. — The  treatment  is  similar  in  principle  to  that  of 
the  unilateral  form.  The  patient  during  the  greater  part  of  the 
course  of  the  disease  must  be  confined  in  the  recumbent  position, 
although  not  necessarily  in  bed.  The  double  Thomas  hip  splint 
is  a  convenient  means  of  fixation.  With  this  apparatus  traction 
by  means  of  the  weight  and  pulley  may  be  employed,  or  the 
brace  may  be  so  modified  as  to  proAide  independent  traction.  If 
the  disease  of  one  hip  is  acute  and  is  attended  by  abscess  forma- 
tion, excision  for  the  purpose  of  lessening  the  strain  upon  the 
patient  may  be  ad\isable. 

Fig.   259 


^^ 

12 

l^r 

w 

^*"r'^ 

Left  hip  disease,  showing  swelling  caused  by  abscess,  also  the  absence  of  flexion  deformity 

If  motion  is  greatly  restricted  in  both  joints  locomotion  unless 
crutches  are  used  is  very  difl&cult  as  motion  at  the  knees  can 
supply  only  in  small  part  the  function  of  the  hip-joints.  In  such 
instances  excision  of  one  hip  in  the  hope  of  obtaining  a  certain 
amount  of  motion  may  be  considered. 

Hip  Disease  Combined  with  Disease  of  Other  Parts. 

The  most  common  combination  is  with  Pott's  disease.  The 
two  processes  may  be  primarily  distinct,  but  occasionally  it  would 
appear  that  the  disease  of  the  hip  is  caused  by  the  infection  of 
an  abscess,  which,  coming  from  the  spine,  remains  *or  a  long 
time  in  contact  with  the  capsule  of  the  joint.  In  five  of  one  hun- 
dred and  fifty  cases  of  disease  of  the  hip-joint  of  which  the  final 
results    were    reported    by    Gibney,    Waterman,    and    Reynolds 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  377 


Fig.  260 


(page  395),  Pott's  disease  was  a  complication,  in  two  instances 
preceding  and  in  three  following  the  disease  at  the  hip.  The 
combination  of  the  two  diseases  makes  the  mechanical  treatment 
diflScult.  Recumbency  offers  the  best  opportunity  for  the  effective 
adjustment  of  apparatus  when  the  disease  of  either  part  is  acute. 

At  a  later  period  crutches  may 
be  employed,  together  with  the 
necessary  braces. 

Hip  Disease  in  Infancy. 

Hip  disease  in  infancy  is  far 
less  common  than  in  early  child- 
hood. It  presents  nothing  of 
special  interest  except  that  its 
effect  upon  the  function  of  the 
joint  and  upon  tlie  development 
of  the  limb  is  usually  more 
marked  than  in  older  subjects. 
Tuberculous  disease  of  this  joint 
must  be  differentiated  from  in- 
fectious epiphysitis,  in  which 
prompt  operative  treatment  is 
indicated.  A  modified  Thomas 
brace  is  most  eflBcient  in  treat- 
ment (Fig.  225). 

Hip  Disease  in  the  Adult. 

Hip  disease  in  the  adult  may 
present  the  typical  symptoms  of 
the  ordinary  form,  but  it  is  usu- 
ally of  the  more  subacute  type. 
Not  infrequently  it  is  a  com- 
plication of  tuberculosis  of  the 
lungs. 

The  subacute  form  of  tuber- 
culous disease  is  often  difficult 
to  distinguish  from  osteoarthritis,  if  this  is  confined  to  the  hip- 
joint.  Gonorrhceal  arthritis  and  impacted  fracture  of  the  neck 
of  the  femur  may  be  mentioned  also  in  differential  diagnosis. 
The  mechanical  treatment  is  not  difficult,  but  in  many  instances 


Untreated  hip  disease.  Slight  flexion  and 
adduction  (apparent  shortening).  The  scar 
of  a  former  abscess  is  seen  on  the  outer 
aspect  of  the  thigh. 


378  ORTHOPEDIC  SURGERY 

early  excision  may  be  ad^^sable  in  order  to  bring  abont  a  rapid 
cure  of  the  disease.  This  is  far  more  important  than  in  child- 
hood, because  few  adults  can  afford  the  time  required  for  the 
natural  cure,  and  because  in  many  instances  the  general  con- 
dition of  the  patient  may  demand  relief  from  the  depressing  effects 
of  the  local  disease,  especially  if  it  be  complicated  by  suppuration. 

Abscess  in  Hip  Disease. 

It  may  be  assumed  that  a  limited  collection  of  the  fluid  prod- 
ucts of  the  tuberculous  process  is  present  in  nearly  every  case  of 
hip  disease  in  which  the  joint  surfaces  are  actually  involved.  In 
many  instances  it  remains  within  the  joint.  In  a  larger  propor- 
tion of  the  cases  the  capsule  is  perforated,  the  fluid  escapes,  and, 
if  the  quantity  is  sufficient  to  form  an  appreciable  tumor,  it  is 
classed  as  an  abscess.  Such  abscesses  may  be  detected  in  about 
50  per  cent,  of  the  cases  that  are  treated  under  ordinary  condi- 
tions. 

In  1370  final  results  collected  from  various  sources  the  per- 
centage of  abscess  was  as  appears  in  the  following  table: 

39  cases  reported  by  Shaffer  and  Lovett' 69.0  per  cent. 

82  "  "         "    Gibney2 60.0 

390  "  "  "    Bruns,^  Tubingen 58.3 

568  "  "  "    Koenig,-*  Gottingen 56.5         " 

125  "  "  "    Sasse,^  Berlin 50.0 

82  "  "  "    Prendlsburger,*  Vienna 51.0  " 

84  "      in  private  practice,  C.  F.  Taylor' 25.0 

Most  often  the  abscess  first  appears  upon  the  anterior  and 
upper  parts  of  the  thigh,  in  the  space  between  the  sartorius  and 
tensor  vaginae  femoris  muscles.  In  other  instances  it  may  be 
detected  first  on  the  inner  side  of  the  thigh,  or  it  may  form  a 
tumor  beneath  the  gluteal  muscles,  its  situation  being  influenced 
by  the  point  at  which  the  capsule  is  ruptured. 

In  rare  instances  the  acetabulum  may  be  perforated  and  a 
pelvic  abscess  may  be  formed,  or  the  pus  may  find  its  way  into 
the  pelvis  along  the  iliopsoas  muscle;  and  occasionally  a  pelvic 
abscess  may  exist  which  appears  to  have  no  direct  communica- 
tion with  the  joint. 

»  New   York   Medical  Journal,   May  21,   1887. 

•■i  New  York  Medical  Ilecord,  March  2,  1878. 

»  Beit,  zur  kiln.  Chir.,  1895,  Bd.  xxx. 

■•  Die  Spec.  TuVjerculone  der  Knoch  u.  Oelenke,  Berlin,  1902. 

'  Arbeit  auH  der  Chir.  kiln,  der  K.  Univ.  Berlin  (Berginann's  clinic),  1896. 

'  Behand.  der  GelenktubercuU>se  und  ihre  lOndresultate  au.s  der  klinik  Alborl,,  Wicn,  1894. 

'  BoBton  Medical  and  .Surgical  .Journal,  March  6,  1879. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  379 

According  to  Koenig^  the  weakest  point  of  the  capsule  is  in 
the  anterior  wall,  where  it  is  covered  by  the  iliopsoas  muscle  and 
by  its  bursa,  which  often  communicate  with  the  joint.  A  second 
weak  place  is  in  the  posterior  wall. 

In  a  total  of  321  abscesses  in  hip  disease  recorded  by  Koenig 
the  situation  was  as  follows: 

On  the  inner  side  (inside  the  femoral  artery) 26 

Front  of  the  joint  (between  artery  and  anterior  superior  spine) .      .      .  126 

Region  of  the  trochanter 63 

Posterior  surface ^^ 

In  the  pelvis 

In  other  situations 1" 

The  tuberculous  abscess  is  a  symptom  and  common  accompani- 
ment of  hip  disease,  which,  in  cases  treated  under  proper  condi- 
tions, is  not  of  great  importance;  and  yet,  on  the  other  hand,  it 

Fig.   261 


Abscess  in  hip  disease. 


The  brace  is  provided  with  the  Thomas  ring  and  with 
the  ratchet  extension. 


is  recognized  as  a  dangerous  complication.  It  is  dangerous  to 
life  because  of  the  profuse  suppuration  that  may  follow  infection, 
and  to  function  because  of  the  adhesions  an  1  contractions  that 
may  result.  This  is  evident  in  all  statistics.  It  is  clearly  shown 
in  those  of  Bruns.  In  this  list  the  mortality  in  the  non-sup- 
purative  cases  was  23  per  cent.,  and  of  the  suppurative  52  per 
cent. 

The  Significance  of  Abscess. — If  abscess  appears  early  in  the 
course  of  the  disease,  it  usually  indicates  that  it  is  of  a  destruc- 
tive character,  and  that  the  interior  of  the  joint  is  involved;  there- 
fore, perfect  function  is  less  likely  to  be  preserved  than  in  those 
cases  in  which  the  disease  has  been  confined  to  the  interior  of 
the  bone. 

'    Loo    cit. 


380  ORTHOPEDIC  SURGERY 

Abscess  formation  is  often  preceded  by  an  acute  exacerbation 
of  s}Tnptoms,  by  pain,  by  an  increase  of  muscular  spasm  and 
consequent  distortion,  and  often  by  an  elevation  of  temperature. 
These  acute  s^Tnptoms  subside  and  a  fluctuating  swelling  appears. 
It  may  be  inferred  that  the  pain  in  such  a  case  was  due  to  the 
tension  of  the  abscess  within  the  capsule,  and  that  the  relief  of 
pain  followed  perforation  and  the  escape  of  the  fluid. 

In  perhaps  the  larger  proportion  of  cases,  more  especially 
those  in  which  the  joint  has  been  protected,  the  formation  of  the 
abscess  is  not  preceded  by  acute  symptoms,  such  as  have  been 
described.  Its  appearance  is  long  delayed,  and  but  for  the  swell- 
ing its  presence  would  not  be  suspected. 

As  the  progress  of  the  disease  is  influenced  by  the  strain  and 
injury  to  which  the  part  is  subjected,  so  abscess,  a  symptom  of 
disease,  is  more  common  in  those  cases  in  which  early  and  effi- 
cient treatment  has  been  neglected;  for  the  same  reason  its  sub- 
sequent course  is  directly  influenced  by  the  protection  that  the 
diseased  joint  receives. 

The  danger  from  abscess  is,  of  course,  infection.  Occasionally 
the  abscess  may  become  infected  before  an  opening  forms.  Such 
infection  may  be  inferred  when  the  tissues  about  the  abscess  are 
hot  and  sensitive,  and  when  fever  is  present;  but,  as  a  rule,  the 
abscess  is  sterile  until  the  skin  is  perforated.  If  the  abscess  sac 
is  small  and  if  drainage  is  efficient,  and  especially  if  communica- 
tion with  the  joint  has  been  occluded,  infection  is  of  slight  con- 
sequence. But  if  before  the  opening  has  formed  the  abscess  has 
[perforated  intermuscular  fasciae  and  has  extended  between  the 
layers  of  muscles  in  various  directions,  infection  is  likely  to  cause 
severe  local  and  constitutional  symptoms.  The  thigh  becomes 
the  seat  of  an  infectious  cellulitis,  pockets  of  pus  form,  which 
cannot  be  properly  drained;  hectic,  emaciation,  and  loss  of  appe- 
tite follow,  and  if  the  profuse  discharge  of  pus  persists  amyloid 
degeneration  of  the  internal  organs  may  result.  Such  patients 
are  said  to  die  of  exhaustion,  but  the  cause  of  exhaustion  is  an 
infected  abscess. 

Treatment. — Admitting  that  abscess  is  a  symptom  whose  im- 
portance stands  in  direct  relation  to  the  care  that  has  been  exer- 
cised in  the  treatment  of  the  disease,  and  that  in  the  better 
class  of  cases  the  danger  from  this  source  is  slight,  still  it  is  also 
true  that  abscess  is  the  chief  cause  of  danger,  and  almost  the 
only  cause  of  death,  in  hip  disease  per  se.  One's  views  as  to  the 
treatment  are  likely  to  be  influenced  by  the  class  of  cases  with 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  381 

which  he  is  most  famihar.  Some  surgeons  have  advocated  abso- 
lute non-interference  with  the  symptomatic  abscess  on  the  ground 
that  in  many  instances  it  finally  disappears  by  spontaneous  ab- 
sorption, while  in  other  cases  the  long  delay  allows  the  com- 
munication with  the  joint  to  close,  so  that  the  danger  of  infection 
after  an  opening  has  formed  is  slight.  Finally,  that  the  results 
after  non-interference  are  better  than  those  reported  after  opera- 
tive treatment.  Others  insist  that  all  collections  of  fluid  of  this 
character  should  be  evacuated  as  soon  as  they  are  discovered, 
because  of  the  danger  of  infection  before  an  opening  forms  and 
because  of  the  advantage  gained  by  preventing  burrowing  of 
pus.  Little  could  be  said  against  this  latter  course  were  it  not 
that  infection  is  as  common  after  operative  treatment  as  when  a 
spontaneous  opening  forms;  the  only  advantage  in  favor  of  the 
artificial  opening  being  that  the  cavity  with  which  it  communi- 
cates should  be  smaller  and  more  direct  than  when  the  fluid 
has  undermined  the  tissues  in  various  directions,  but  this  is  offset 
by  the  fact  that  at  least  20  per  cent,  of  abscesses  disappear  with- 
out treatment.  In  fact,  as  compared  with  indiscriminate  incisions, 
the  let-alone  treatment  should  be  preferred  when  proper  after- 
treatment  cannot  be  assured. 

It  would  appear,  however,  that  the  middle  course,  between  the 
extremes,  is  the  safest,  and  especially  so,  as  by  far  the  larger 
number  of  patients  must  be  treated  under  conditions  that  do  not 
permit  of  proper  care.  In  the  out-door  department  of  the  Hos- 
pital for  Ruptured  and  Crippled  abscesses  are  treated  symptom- 
atically.  If  a  swelling  appears  but  remains  quiescent  and  causes 
no  symptoms  it  is  not- disturbed.  If  it  enlarges,  the  tension  of 
the  fluid  is  relieved  by  aspiration,  which  may  be  repeated  as 
required,  compression,  after  the  evacuation  of  the  fluid,  Ijeing 
applied  by  means  of  a  pad  and  bandage.  If  the  contents  are  of 
such  a  nature  that  aspiration  is  impossible,  a  small  incision  is 
made,  the  contents  are  expressed  and  the  opening  is  immediately 
closed  with  one  or  more  sutures.  This  procedure  by  which 
infection  is  avoided  may  be  repeated  at  intervals.  It  may  be 
employed  also  when  deep-seated  abscess  within  the  joint  causes 
painful  tension. 

If  the  abscess  is  of  large  size,  or  if  acute  symptoms  are  present, 
the  child  is  admitted  to  the  hospital.  Here  the  same  general 
principle  is  followed,  but  in  certain  instances  it  may'*'be  thought 
advisable  to  explore  the  joint  in  addition  to  opening  the  abscess. 
In  such  cases  the  incision  must  be  longer,  the  woimd  is  then  closed 


382  ORTHOPEDIC  SURGERY 

\\\i\i  superficial  and  deep  sutures,  and  a  firm  dressing  is  applied. 
This  operation,  if  performed  under  aseptic  precautions,  causes 
no  disturbance,  and  it  relieves  nature  from  the  burden  of  necrotic 
material  which  must  be  an  obstacle  to  spontaneous  absorption. 
In  many  instances  the  abscess  is  permanently  cured,  although 
if  the  condition  that  induced  it  remains  unchanged  fluid  will 
again  accumulate,  and  if  so  a  spontaneous  opening  will  form 
in  the  line  of  the  incision.  This  operation  is  not  a  radical  cure  of 
the  abscess  or  of  the  disease;  it  is  simply  a  means  of  thorough 
evacuation  for  the  purpose  primarily  of  accomplishing  what  the 
aspirator  does  only  in  part.  If  the  abscess  has  become  infected 
its  contents  are  completely  removed,  the  wound  is  then  packed 
"v\nth  gauze,  and  provision  is  made  for  efficient  drainage. 

In  the  treatment  of  abscesses  the  injection  of  iodoform  emulsion, 
in  connection  with  the  aspiration  or  incision,  has  been  thoroughly 
tested.  The  results,  as  far  as  the  disappearance  of  the  abscess 
was  concerned,  were  not  as  good  as  from  simple  aspiration;  and 
as  the  procedure,  being  somewhat  of  the  nature  of  an  operation, 
caused  the  patients  some  discomfort  and  anxiety,  it  was  discon- 
tinued. From  the  clinical  standpoint  there  is  little  evidence 
that  these  injections  exercise  any  particular  influence  upon  the 
disease,  but,  theoretically,  iodoform  should  lessen  the  infectious- 
ness of  the  tuberculous  fluid,  and  by  local  irritation  stimulate  the 
growth  of  granulation  tissue.  There  appears  to  be  no  serious 
objection  to  its  use. 

The  Treatment  of  Sinuses. — When  the  disease  is  active  the 
sinuses  that  serve  as  drains  should  not  be  disturbed.  And  in 
the  advanced  cases  when  disease  is  quiescent  and  when  the  tis- 
sues about  the  joint  are  of  the  peculiar,  resistant,  "porky"  con- 
sistency, active  measures,  either  for  the  purpose  of  closing  sinuses 
or  for  the  correction  of  deformity,  should  be  deferred.  In  many 
instances,  however,  sinuses  persist  as  tuberculous  fistulse,  serving 
no  useful  purpose.  In  this  class  the  complete  removal  of  the 
infected  tissue  by  excision  or  by  thorough  curetting  is  the  most 
effective  remedy.  The  various  applications  of  pure  carbolic 
acid,  solution  of  salicylic  acid,  iodoform  emulsion,  balsam  of 
Peru,  and  the  like  are  of  some  service,  but  thorough  removal 
of  the  disease  is  the  only  radical  treatment. 

Exploratory  Operations. — In  certain  instances  exploratory  opera- 
tions may  be  inthcated.  If,  for  example,  pain  and  swelling 
indicate  tension  within  the  capsule  it  may  be  relieved  by  a 
small  direct    incision    or   the    joint   may    be    explored   with  the 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  383 

possibility  of  finding  a  localized  focus  of  disease  that  may  be 
removed . 

The  joint  may  be  opened  by  an  anterolateral  incision,  begin- 
ning one  inch  to  the  outer  side  of  the  anterior  superior  spine  and 
extending  downward  about  three  inches.  This  exposes  the  line 
of  junction  between  the  tensor  vaginae  femoris  and  the  gluteus 
medius  muscles.  When  these  are  separated  from  one  another  the 
anterior  surface  of  the  capsule  of  the  joint  is  laid  bare.  If  more 
room  is  required  the  tensor  vaginae  femoris  muscle  may  be  divided. 
The  capsule  is  then  incised  in  the  line  of  the  neck  and  through 
the  incision  the  head  of  the  bone  may  be  extruded  by  rotating 
the  limb  outward  and  extending  it.  By  this  means  the  character 
of  the  disease  may  be  ascertained  and  in  certain  instances  local- 
ized foci  in  the  neck  or  in  the  head  of  the  bone  may  be  removed. 
The  wound  is  then  closed  or  drained  as  may  seem  ad\isable. 
By  such  intervention  the  course  of  the  disease  may  be  shortened, 
although  cure  by  this  means  is  unusual. 

Temporary  anterior  dislocation  of  the  head  of  the  femur  by 
means  of  the  anterolateral  incision  may  be  of  value  in  acute  and 
painful  disease.  Posterior  dislocation  for  this  purpose  has  been 
performed  by  Bradford  in  several  cases  with  satisfactory  results, 
the  bone  being  again  replaced  when  the  disease  had  become  qui- 
escent.^ The  object  of  this  operation  is  to  remove  the  opposing 
bones  from  direct  contact,  and  to  relieve  the  muscular  spasm  that 
accompanies  acute  disease. 

Exploratory  operations  may  be  of  special  value  in  the  later 
stages  of  the  disease,  to  ascertain  the  cause  of  long-continued 
suppuration,  or  of  abnormal  delay  in  repair,  which  may  be  due 
to  detached  or  adherent  fragments  of  necrosed  bone  within  the 
joint.  This  point  is  illustrated  by  the  statistics  of  61  cases  of 
hip  disease  treated  by  excision  by  Poor.^  In  15  of  these  loose 
bone  was  found  in  the  joint,  and  in  7  the  head  of  the  bone  was 
detached. 

In  98  cases  investigated  by  Lehman^  at  the  Wurzburg  clinic 
sequestra  were  present  in  20.4  per  cent.,  and  in  70  per  cent,  of 
88  cases  treated  by  Riedel.^ 

An  exploration  of  the  joint  by  one  familiar  with  surgical 
technique  should  be  free  from  danger,  and  it  may  be  of  much 
value. 

1  Transactions  of  the  American  Orthopedic  Association,  vol.  xiii. 

-  New  York  Medical  Journal,  April  23,  1892. 

•'  Inaug.  Diss.,  Wiirzburg,   1896. 

*  Centralbl.  f.  Chir.,  1893,  Bd.  xx.,  Nos.  7  and  8. 


384  ORTHOPEDIC  SURGERY 

Excision  of  the  Hip. — The  operation  of  excision  is  now  classed 
as  a  treatment  of  necessity  in  certain  cases,  usually  those  in  which 
recovery  under  conservative  treatment  is  considered  very  doubt- 
ful. For  example,  when  there  is  progressive  failure  in  health; 
when  it  is  impossible  to  drain  the  joint  effectively  after  infection; 
when  there  is  e\'idence  of  extension  of  the  disease  to  the  shaft 
of  the  femur  or  to  the  pehdc  ca^'ity,  or  when  other  serious  com- 
plications exist. 

In  certain  instances  the  excision  may  follow  an  exploratory 
operation;  in  such  cases  the  anterolateral  incision  may  be  em- 
ployed and  the  neck  and  head  of  the  bone  only  may  be  removed. 
In  this  operation  the  diseased  tissue  is  removed  as  thoroughly  as 
possible  with  the  sharp  spoon,  by  scrubbing  with  iodoformized 
gauze,  and  by  flusliing  with  hot  water.  If  the  joint  is  not  in- 
fected it  is  dried;  iodoform  emulsion  may  be  injected  or  the  pure 
carbolic  acid  may  be  applied,  and  the  various  tissues  are  then 
sewed  in  layers;  pressure  is  applied,  the  aim  being  to  secure  im- 
mediate union.  If  this  does  not  take  place  drainage  is  employed 
in  the  usual  manner. 

In  typical  cases  the  operation  is  performed  because  of  exten- 
sive disease  and  infected  abscess,  and  in  such  instances  usually 
the  entire  upper  extremity  of  the  bone  to  the  trochanter  minor  is 
removed. 

A  satisfactory  method  is  that  of  Koenig. 

An  incision  about  five  inches  in  length  is  made  in  a  line  join- 
ing the  trochanter  and  the  posterior  inferior  spine  of  the  ilium. 
About  two-thirds  of  the  length  is  above  and  one-third  over  the  tro- 
chanter. The  incision  is  deepened  to  expose  the  capsule  and  the 
surface  of  the  trochanter,  from  which  one  removes  the  insertion 
of  the  gluteus  maximus  and  the  tendons  of  the  medius  and  mini- 
mus. The  muscles  are  separated  in  the  line  of  the  incision  and 
the  capsule  is  widely  opened.  With  a  thick,  strong  knife  one 
detaches  all  the  muscular  attachments  to  the  anterior  margin 
of  the  trochanter,  while  the  limb  is  rotated  outward,  removing, 
if  possible,  a  thin  section  of  periosteum  and  bone.  The  same 
process  is  then  repeated  on  the  posterior  surface,  the  limb  being 
rotated  inward.     The  trochanter  is  then  removed. 

The  acetabular  insertion  of  the  capsule,  together  with  the 
adjoining  upper  border  of  the  acetabulum,  is  then  cut  away  and 
the  neck  of  the  femur  is  separated  from  the  shaft  with  a  saw 
or  chisel.  All  the  diseased  parts  are  then  removed,  including  the 
acetabular  wall  and   adjoining  bone,  if  necessary.     The  wound 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


385 


is  partly  closed  with  drainage,  and  the  extremity  of  the  femur  is 
placed  within  the  acetabulum,  where  it  should  be  retained  for  a 
time  by  a  plaster  bandage  or  Thomas  brace  provided  with  trac- 
tion straps.  Wlien  the  patient  begins  to  walk  a  hip  splint  or 
other  support  is  used  for  a  time  to  prevent  deformity.  One  of 
the  most  efficient  supports  of  this  class  is  the  short  or  Lorenz 
spica,  the  limb  being  fixed  in  an  attitude  of  overextension  and 
moderate  abduction  for  many  months. 

Another  form  of  incision  is  that  of  Rydygier*  shown  in  the  ac- 
compan}ang  illustration.  The  flap  is  lifted,  the  trochanter  major 
is  cut  through  and  with  its  attached  muscles  turned  upward.     The 

Fig.  262 


Rydygier's  incision  for  excision  of  the  hip. 

capsule  is  then  opened  and  the  femur  is  dislocated  for  inspec- 
tion. All  the  diseased  parts,  including  the  entire  acetabulum,  if 
necessary,  together  with  the  capsule,  are  then  removed.  Com- 
plete removal  of  the  acetabulum  Ls  indicated  when  it  is  perforated, 
a  procedure  particularly  advocated  by  Bardenheuer. 

The  success  or  failure  of  excision  of  the  hip  as  a  life-saving 
operation,  provided  the  diseased  bone  has  been  removed,  is  de- 
cided by  the  after-treatment,  and  in  this,  drainage  is  the  great 
essential.  The  opening  must  be  large  and  the  shaft  of  the  bone 
must  be  drawn  down  by  efficient  traction,  so  that  it  may  not 
obstruct  the  opening,   and   the   exuberant  granulations  must  be 

1   MosetiK-Moorhof,  Wiener  klin.  Wochen.,  No.  20,  1905. 
-  Deutsch.  Gesells.  f.  Chir.,  XXXV.  Kongress,  1906. 
25 


386  ORTHOPEDIC  SURGERY 

removed  from  time  to  time.  Phelps  has  introduced  a  valuable 
adjunct  in  the  use  of  short,  glass  drainage  tubes  of  large  diameter, 
even  up  to  one  and  one-half  inches.  Through  such  a  tube  or 
speculum  the  gauze  is  inserted,  the  opening  permitting  thorough 
inspection. 

The  importance  of  an  open-air  life  after  these  operations  can 
hardly  be  exaggerated.  The  lack  of  this,  the  inefficiency  of  the 
after-treatment  in  securing  proper  drainage,  and  the  postponement 
of  the  operation  until  amyloid  changes  are  advanced  explain  the 
unsatisfactory  character  of  the  results. 

The  functional  results  after  excision  in  this  class  of  cases  are 
not  as  good  as  those  that  may  be  obtained  when  the  operation  has 
been  performed  at  an  earlier  period.  If  motion  continues  free  the 
joint  is  usually  insecure.  In  many  instances  there  is  upward 
displacement  of  the  shaft  of  the  femur  upon  the  ilium  with  con- 
sequent flexion  and  adduction  deformity,  while  in  a  third  class  of 
cases  a  movable  joint  of  sufficient  strength  may  be  preserved. 
The  ultimate  shortening  is  considerably  greater  than  after  con- 
servative treatment.  This  is  accounted  for  by  the  upward  dis- 
placement of  the  femur  and  by  the  removal  of  the  two  epiphyses 
of  its  upper  extremity. 

In  a  period  of  twelve  years,  1888  to  1899,  inclusive,  149  opera- 
tions of  excision  were  performed  at  the  Hospital  for  Ruptured  and 
Crippled.  During  this  time  1283  cases  of  hip  disease  were  treated 
in  the  wards  and  1870  new  cases  were  recorded  in  the  out-patient 
department.  Thus  the  operation  was  performed  in  11.6  per  cent, 
of  those  in  the  hospital,  but  the  relative  frequency  of  the  opera- 
tion in  the  entire  number  of  patients  under  treatment  was  con- 
siderably less  than  this. 

One  hundred  and  twenty-one  of  these  operations  of  excision, 
or  those  performed  prior  to  1897,  have  been  carefully  analyzed 
by  Townsend.^  The  121  operations  were  performed  on  119 
patients,  in  two  instances  both  hips  having  been  operated  upon. 
In  113  abscesses  or  sinuses  were  present,  in  most  instances 
infected.  In  5  cases  the  spine  was  involved  as  well  as  the  hip; 
in  2  instances  the  knee;  in  2  the  tarsus;  in  3  the  ilium.  In 
24  the  anterior  incision  was  employed,  in  97  the  posterior. 
In  18  instances  the  acetabulum  was  seriously  diseased,  and  in  10 
osteomyelitis  of  the  shaft  of  the  femur  was  present.  This 
indicates  the  character  of  the  disease  in  the  cases  operated 
upon. 

'   Medical  News,  June  26,    1897. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


387 


In  99  of  the  119  cases  the  later  results  of  the  operation  were 
ascertained.  Of  these  52  were  dead  and  47  were  living.  Of  the 
52  deaths  9  were  due  directly  to  the  operation,  shock;  28  were 
caused  by  exliaustion  (persistent  suppuration);  9  by  tuberculous 
meningitis;  7  by  other  causes.  Thirty-seven  deaths  occurred 
within  six  months  and  10  others  within  one  year  of  the  operation. 
Of  the  47  patients  living  at  the  time  of  the  investigation,  26  were 
cured.  Of  the  remaining  number  about  one-half  were  in  poor  con- 
dition, so  that  recovery  could  not  be  expected.  It  is  e\'ident  that 
in  a  large  proportion  of  the  cases  the  operation  was  unsuccessful 
as  a  life-saving  measure,  since  suppuration  persisted.  The  func- 
tional results  in  these  cases  are  shown  in  the  following  table : 

Table  Showing  Shortening,  Motion,  Number  of  Sinuses  Present, 
AND  Angle  of  Greatest  Extension  in  Forty-seven  Cases  of 
Excision.    (Townsend.) 


Angle  of 

No. 

Time  since 

General 

Sinuses 

greatest 

Motion  in 

Shortening 

operation. 

j   condiiion. 

present. 

extension. 

degrees. 

in  inches. 

1 

6^  years 

Good 

3 

loO 

0 

2K 

2 

6«4      " 

Fair 

1 

135 

0 

4 

3 

6         " 

Good 

0 

ISO 

100 

3 

4 

Wx      " 

•' 

0 

ISO 

35 

3 

5 

SK     " 

Fair 

0 

115 

10 

4 

6 

5K      " 

Gond 

1 

165 

0 

1% 

7 

5 

" 

0 

155 

5 

2K 

8 

4K      " 

" 

3 

160 

0 

2 '.4 

9 

4^      " 

" 

0 

160 

0 

"^H 

10 

4J4     " 

" 

0 

165 

0 

IH 

11 

4 

" 

0 

150 

0 

12 

4 

Poor 

4 

0 

13 

3^      " 

Good 

0 

155 

0 

IM 

14 

^'A      " 

0 

160 

30 

1 

15 

3 

Poor 

1 

165 

0 

H 

lf> 

2         " 

Fair 

2 

145 

30 

y* 

17 

2 

<TOod 

18 

2 

Fair 

1 

170 

0 

Vt 

19 

2 

Good 

0 

150 

0 

3^ 

20 

IK      " 

" 

0 

175 

Yi 

21 

IK      " 

" 

0 

165 

30 

%. 

22 

1'2         " 

" 

0 

150 

0 

1 

23 

V4     " 

" 

0 

150 

0 

VA 

24 

1'^     " 

" 

1 

ISO 

0 

% 

25 

i]4    " 

Fair 

6 

1?5 

15 

1* 

26 

1 

Poor 

2 

165 

0 

2J^ 

27 

1 

Good 

0 

170 

0 

1>^ 

28 

1 

" 

0 

155 

0 

1 

29 

1 

" 

0 

175 

0 

Yi 

30 

1 

Poor 

0 

ISO 

10 

i^i 

31 

11    ninnllis 

3 

170    . 

0 

y* 

32 

10 

" 

0 

ISO 

40 

IV, 

33 
34 

10 
10 

Good 

3 

0            i 

165 
160 

0 
0 

/2 

35 

10 

1.           1 

165 

0 

1 

36 

10 

Poor 

1 

Ifil) 

0 

^ 

37 

10 

Good 

3 

155 

10 

IJi 

3S 
39 

9 

.. 

1 
0 

0 

72 

40 

9          "         1 

Poor 

1 

170 

"6 

41 

9      "      ; 

Fair 

3 

1 

42 

M 

Good 

0 

ISO 

130 

^ 

43 

8          "         i 

" 

0 

180 

44 

8 

Poor 

1 

165 

10            1 

K 

45   - 

7 

" 

4fi 

7 

Good 

0 

ISO 

10 

1^ 

47 

7         "        1 

1 

0 

ICO 

70 

V*' 

388  ORTHOPEDIC  SURGERY 

Lovett^  has  reported  the  results  of  50  excisions  in  a  similar 
class  of  cases  at  the  Boston  Children's  Hospital,  1877  to  1895. 
The  number  of  patients  actually  treated  in  the  wards  of  the  hos- 
pital is  not  stated,  but  1100  cases  were  recorded  as  having  been 
under  treatment  during  this  time,  a  percentage  of  excisions  of 
4.5  of  the  total  number.  In  8  of  the  cases  osteomyelitis  of  the 
femur  was  present,  and  in  15  the  acetabulum  was  perforated. 
The  ultimate  mortality  was  about  50  per  cent. 

Poor  has  reported  the  results  in  65  cases  operated  upon  at 
St.  Mary's  Hospital,  New  York,  with  a  final  mortality  of  about 
34  per  cent.  In  21  cases  osteomyelitis  of  the  shaft  of  the  femur 
was  present.  In  11  cases  there  was  perforation  of  the  acetabulum, 
and  in  9  of  these  the  opening  communicated  with  an  intrapelvic 
abscess. 

These  statistics  are  quoted  to  illustrate  the  relative  efficiency 
of  late  excision.  The  extent  of  the  lesions  in  some  of  the  cases 
shows  that  recovery  would  have  been  impossible  without  opera- 
tion, and  its  failure  to  relieve  the  symptoms  in  so  many  instances 
is  sufficient  evidence  that  it  was  postponed  too  long.  Under 
proper  conditions  for  treatment  excision  of  the  hip  is  almost 
never  required,  but  in  hospital  practice  it  should  be  performed 
oftener  and  earlier  in  the  course  of  the  disease. 

Amputation. — Amputation  at  the  hip  should  follow  excision 
when  suppuration  persists  and  when  the  condition  of  the  patient 
does  not  improve,  provided  the  internal  organs  are  not  hopelessly 
diseased.  The  operation  of  amputation  after  complete  excision  is 
a  simple  procedure  and  it  should  not  be  attended  with  great  danger. 

Reduction  of  Deformity  in  Resistant  Cases. — The  various  methods 
of  rc^Iucing  deformity  during  the  active  stages  of  the  disease  have 
been  described,  and  the  importance  of  preventing  deformity 
throughout  the  entire  course  of  treatment  has  been  insisted  on. 
At  the  present  time,  for  one  reason  or  another,  deformity  from 
this  cause  is  very  common,  either  because  its  importance  is  not 
appreciated  or  because  it  is  considered  as  a  necessary  concomitant 
of  the  disease,  treated  by  apparatus,  as  it  is  in  the  natural  cure. 
At  all  events,  in  many  instances  it  is  allowed  to  persist  until  the 
accommofjative  changes  about  the  diseased  joint  have  so  fixed  the 
limb  in  the  deformed  position  that  greater  correcting  force  is 
recjuired  t'lan  can  be  applied  by  the  weight  and  pulley  or  by 
other  method  of  traction. 

'   TransactioriH   Amerioiin  Orthopedic  AHHociation,  vol.  x. 
2   New   York  Medical  Journal,  April  23,   1892. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


389 


In  this  class  of  cases,  in  which  the  muscles  are  stnicturally 
shortened  and  in  part  transformed  to  fibrous  tissue,  and  in  which 
the  anterior  wall  of  the  capsule  has  become  retracted  and  adherent 
to  the  surrounding  parts,  forcible  reduction  imder  anaesthesia,  or 
osteotomy,  may  be  required.  If  the  disease  is  quiescent  or  cured, 
if  the  head  of  the  femur  or  what  remains  of  it  is  in  the  normal 
position,  and  if  a  fair  range  of  motion  remams,  gradual  forcible 

Fig.  263 


Extreme  deformity  after  hip  disease,  showing  the  attitude  before  operation. 
(See   Figs.   26-t  and  268.) 

reduction   after  division  of  the  bands  of  fascia  or  the  muscles 
that  hold  the  limb  in  the  deformed  position  is  advisable. 

In  all  cases  in  which  the  head  of  the  bone  is  destroyed  the 
aim  should  be  to  secure  an  anterior  transposition  of  the  upper 
extremity  of  the  femur,  and  to  secure  this  result  one  proceeds 
as  in  reducing  or  transposing  the  congenitally  displaced  hip — 
by  longitudinal  traction,  by  forcible  abduction,  combinetl  with 
massage  of  the  adductors,  and,  finally,  by  gradual  extension — 


390  OE THOPEDIC  S  UR GEB  Y 

preceded  usually  by  dhnsion  of  tlie  resistant  parts  about  the 
anterior  superior  spine.  The  limb  is  then  fixed  by  a  Lorenz 
spica  in  an  attitude  of  moderate  abduction  and  overextension. 
Later  the  abduction  is  lessened,  but  the  overextended  position 
is  maintained  for  many  montlis,  and  is  assured  by  passive  move- 
ments after  the  support  is  removed.  Forcible  reduction  in  cured 
or  quiescent  cases  is  practically  free  from  danger. 

The  Correction  of  Deformity  by  Femoral  Osteotomy. — If  the 
deformity  is  fixed  by  bony  anchylosis  or  by  firm,  fibrous  adhesions 
within  the  joint;  or  if  it  is  feared  that  violence  may  stimulate 
dormant  disease;  or  if  there  is  such  a  degree  of  upward  displace- 
ment of  the  femur  upon  the  pelvis  that  the  deformity  is  Hkely  to 
recur  after  replacement,  it  is  better  to  correct  the  deformity  by  an 
osteotomy  of  tlie  femur. 

Fig.  264 


The  favorite  attitude  in  recumbency.     (See  Fig.  263.) 

The  patient  having  been  prepared  for  operation,  is  turned  upon 
the  side  and  a  sand-bag  is  placed  between  the  thighs.  A  small 
osteotome,  about  the  shape  of  a  lead-pencil,  of  which  one  extremity 
is  flattened  to  a  cutting  edge  (Vance's  instrument),  is  pushed 
directly  through  the  soft  parts  to  the  femur  at  a  point  about  two 
inches  below  the  apex  of  the  trochanter.  It  is  turned  until  its 
cutting  edge  is  at  the  right  angle  to  the  shaft  and  it  is  then  driven 
through  the  cortical  substance  of  the  bone.  When  it  has  pene- 
trated at  one  point  it  is  withdrawn,  and  adjoining  portions  are 
cut  until  about  half  the  circumference  is  divided,  when  with 
slight  force  the  bone  may  be  fractured.  If  the  deformity  is  of 
long  standing,  division  of  the  contracted  tissues  in  the  adductor 
region  and  below  the  anterior  superior  spine  may  be  required. 

The  limb  is  then  drawn  down  to  complete  extension  and  mod- 
erate abduction,  and  the  body  and  limb  are  encased  in  a  plaster- 
of-Paris   spica  bandage,  which    should    remain   in    position   for 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT 


391 


Fig.  265 


several  montls,  although  tlie  patient  may  be  allowed  to  bear 
weight  on  the  limb  a  few  weeks  after  the  operation.  Tl  e  long 
may  be  replaced  by  the  short  spica  at  the  end  of  two  months. 
This  latter  or  some  similar  appliance  should  be  used  until  tests 
show  that  there  is  no  longer  danger  of  recurrence  of  the  deformity. 

The  advantages  of  the  subcutaneous 
method  are  simplicity  and  freedom  from 
danger.  No  dressings  are  required,  ex- 
cept a  pad  of  gauze  over  the  minute 
opening;  thus  the  limb  may  be  firmly  held 
by  the  plaster  bandage.  If  there  is  anchy- 
losis between  the  femur  and  the  pelvis  no 
support  will  be  required  after  the  bone 
has  united,  but  if  there  is  motion  in  the 
joint  some  fixative  appliance  should  be 
employed  for  a  time  to  prevent  recur- 
rence of  a  part  of  the  deformity. 

Prognosis.  Mortality. — ^The  direct  mor- 
tality of  hip  disease  is  due  almost  entirely 
to  the  immediate  or  remote  effects  of  ab- 
scess. This  is  illustrated  by  the  statistics 
of  Bruns,  in  which  the  mortality  from  all 
causes  of  the  non-suppurative  cases  was 
23  per  cent,  as  compared  with  52  per 
cent,  in  those  in  whom  suppuration  was 
present. 

The  mortality  among  the  patients 
treated  at  many  of  the  German  clinics  is 
much  higher  than  in  the  corresponding 
class  in  this  country. 

At  Tubingen,  according  to  Wagner,*  it 
was  40  per  cent. 

At  Kiel,  according  to  Mummelthy,  it 

^o  rr\  I    '  ■•  After  correct  io.i  uy  osteotomy 

was  48.59  per  cent,  m  non-operative  cases  and  division  of  the  contracted 
and  53.96  per  cent,  in  operative  cases.        Sd"24if  ^'"'^'''^  (See Figs. 24o 

At  Marburg,  according  to  Marsch,  it 
was  35  per  cent,  in   non-operative  cases  and  40.4   per  cent,  in 
operative  cases. 

At  Heidelberg,  according  to  Huismans,^  it  was  46.6  per  cent, 
in  non-operative  cases  and  58  per  cent,  in  operative  cases. 


1   Beit.  z.  klin.  Chir.,  189.5,  Bd.  xiii. 

■  Quoted  by  Binder,  Zeits.  f.  Orthop.  Chir.,  1889.  Bd.  vii.,  H.  2  und  3. 


392  ORTHOPEDIC  SURGERY 

At  Zurich,  according  to  Pedolin/  it  was  37.7  per  cent,  in  non- 
operative  cases  and  54  per  cent,  in  operative  cases. 

At  Vienna,  according  to  Prendlsburger,"  it  was  17  per  cent, 
in  all  classes. 

At  Gottingen,  according  to  Koenig,^  40.3  per  cent. 

In  a  total  of  636  cases  treated  by  conservative  methods  by  Rabl, 
1S59  to  1894,  definite  results  were  ascertained  in  519;^  335  were 
hospital  cases.  Of  these  216  were  cured,  64.4  per  cent.;  70  died, 
20.8  per  cent.,  and  49,  14.4  per  cent.,  were  still  under  treatment; 
184  were  treated  as  out-patients.  Of  these,  132  were  cured, 
71.5  per  cent.;  35  died,  19.2  per  cent.,  and  17,  92  per  cent.,  re- 
mained under  treatment. 

In  288  cases  treated  at  the  Hospital  for  Ruptured  and  Crippled, 
New  York,  reported  by  Gibney,^  the  death-rate  was  12.5  per  cent. 

In  private  practice  the  statistical  reports  of  final  results  show 
the  death-rate  to  be  extremely  small.  C.  F.  Taylor,®  94  cases, 
including  24  in  which  suppuration  was  present,  3  deaths. 
L.  A.  Sa}Te,^  212  cases,  5  deaths.  Lorenz,^  60  cases,  with  3 
deaths. 

In  the  clinics  of  this  country  the  death-rate  has  been  estimated 
to  be  from  10  to  15  per  cent.,  a  rate  of  mortality  much  lower 
than  that  reported  from  those  abroad.  This  is  accounted  for  in 
part  by  the  fact  that  patients  are  of  a  better  class  and  in  part 
because  they  receive  earlier  and  more  efficient  mechanical  pro- 
tection. 

The  causes  of  death,  according  to  Wagner's  statistics  of  124 
cases,  were  as  follows: 

Hip  disease 35 

General  tuberculosis 37 

Tuberculous  meningitis 13 

Tuberculosis  of  the  lungs ....  11 

Acute  miliary  tuberculosis 5 

Amyloid  degeneration 8 

Septic  infection 12 

Intercurrent  disease 3 

124 

Thirty  per  cent,  of  the  deaths  occurred  in  the  first  year  of  the 
disease,  26  per  cent,  in  the  second  year,  and  20.4  per  cent,  in  the 
third  year. 

'   Centralbl  f.  Chir.,  .July  2.5,  1890,  No.  30.  -  Loc.   cit. 

■■'  Koenig,  Das  HoeftKelcnk,   Berlin,   1902. 

*  Zur  Owiserv.  Behand.  der  tuberculoscn  Knochen  und  Gelenksleiden,  J.  Rabl,  Leipzig 
und   Wien,    189.5. 

*  New  York  Medical  .rouriial,  .July  and  A\iKUHt,  1877. 

«  Boston   Meilifial  and  Surgical  .lounial,   March  0,   1879. 
'  New   York   Medical  .Journal,   April   .'JO,    1892. 
«  Wiener  Klinik,   1892,    10  and    11. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  393 

The  percentage  of  recovery  was  65  per  cent,  of  those  in  the 
first  decade  of  Ufe,  56  per  cent,  of  those  in  the  second,  and  but 
28  per  cent,  of  those  in  the  third  decade. 

The  causes  of  death  in  50  cases  among  778  patients  treated  at 
the  New  York  Orthopedic  Dispensary  and  Hospital  during  the 
years  1877  to  1882  were:^ 

Tuberculous  meningitis 20 

Amyloid  degeneration 5 

Exhaustion 3 

Tuberculosis  of  the  lungs 3 

Tuberculous  peritonitis 1 

Septicaemia 1 

Convulsions 1 

Unknown 16 

50 

Of  96  deaths  recorded  at  the  Alexandra  Hospital,  London  (a 
mortality  of  about  26  per  cent,  of  the  cases  treated),  the  causes 
were 

Tuberculous  meningitis 16.1  per  cent. 

Albuminuria  and  dropsy 20.8  " 

Tuberculosis  of  the  lungs 8.3  " 

Exhaustion 9.4  " 

Erysipelas  and  pyaemia 3.1  " 

After  operation 9.4  " 

Intercurrent  diseases 7.3  " 

Unknown 25.0  " 

100.0       " 

The  direct  mortality  of  hip  disease  should  include  all  deaths 
due  to  operation,  those  caused  by  exhaustion,  and  amyloid  degen- 
eration, which  is  almost  always  the  result  of  profuse  suppuration 
secondary  to  pyogenic  infection.  Tuberculous  meningitis,  a  com- 
mon and  apparently  an  unavoidable  cause  of  death,  is  not  neces- 
sarily a  complication  of  the  local  disease,  except  in  so  far  as  a 
lowered  vitality  may  predispose  the  patient  to  it,  since  it  may 
have  been  due  to  new  infection  or  induced  by  the  primary  focus 
which  preceded  the  tuberculosis  of  the  hip. 

It  is  believed  that  operative  interference  is  sometimes  the  direct 
cause  of  tuberculous  meningitis,  and  it  is  of  interest  in  this  con- 
nection to  note  that  20  of  50  deaths,  or,  rather  of  34,  in  which  the 
cause  of  death  was  known  (58  per  cent).,  were  due  to  this  com- 
plication among  the  cases  treated  at  the  New  York  Orthopedic 
Dispensary  and  Hospital,  where  no  operations  were  performed.' 
While  of  52  deaths  in  a  total  of  99  cases  treated  at  the  Hospital 
for  Ruptured  and  Crippled,  in  wliich  excision  was  performed, 
but  9  were  caused  by  tuberculous  meningitis. 


3 


1  Shaffer  and  Lovett,  New  York  Medical  Journal,  May  21,  1887 

2  Ibid. 

^  Townsend,  Medical   News,   June   2G,    1896. 


394  ORTHOPEDIC  SURGERY 

The  normal  death-rate  among  cases  under  fair  hygienic  condi- 
tions is  iUustrated  by  statistics  from  the  Hospital  for  Ruptured 
and  Crippled  at  a  time  when  no  operative  or  mechanical  treat- 
ment was  employed.^  This  was  12.5  per  cent.;  4.5  per  cent. 
from  exliaustion,  4.5  per  cent,  from  amyloid  degeneration,  1.75 
per  cent,  from  tuberculous  meningitis,  1.75  per  cent,  from  inter- 
current diseases. 

Thus  nearly  75  per  cent,  of  the  deaths  were  due  more  or  less 
directly  to  suppuration. 

Functional  Results. — In  a  certain  proportion  of  cases  perfect 
function  may  be  retained,  the  proportion  depending  upon  the 
extent  of  the  disease,  and  upon  the  timeliness  and  efficiency  of 
the   treatment. 

In  a  total  of  280  cases  from  the  private  practice  of  Dr.  L.  A. 
Sayre,^  in  which  the  final  results  were  known,  73,  or  26  per  cent., 
recovered  with  perfect  motion,  and  120  or  42  per  cent.,  retained 
good  motion.  These  results  are  extraordinarily  good,  very  much 
better  than  any  others  that  have  been  reported,  and,  of  course, 
far  better  than  may  be  expected  in  the  ordinary  class  of  cases. 

The  effect  of  mechanical  treatment  and  of  the  various  measures 
employed  for  the  correction  of  deformity  is  well  illustrated  in 
two  series  of  ultimate  results  in  cases  treated  at  the  Hospital  for 
Ruptured  and  Crippled,  reported  by  Gibney.^  In  the  first  series 
of  80  cases  no  mechanical  or  operative  measures  were  employed, 
the  treatment  being  simply  hygienic  and  symptomatic;  the  re- 
sults, therefore,  represent  natural  cure  under  proper  supervision. 
The  duration  of  the  disease  was  three  years  in  23;  three  to  six 
years  in  28;  six  to  ten  years  in  16,  and  fifteen  years  in  one  case. 

In  35  cases  the  shortening  was  two  inches  or  more,  and  in 
nearly  every  case  there  was  more  or  less  deformity,  viz. : 

In    2  there  was  flexion  to 90° 


"  3 
"  3 
•'  19 
"  19 
"  18 
"  11 


.  110 
120 
135 
145 
150 

lGO-170 


In  4  no  estimate  was  made.     Distortions  other  than  flexion 
are  not  specified. 

In  12  instances  motion  was  retained  of  from  15  to  90  degrees. 

'  Gibney,  New  York  Medical  Record,  March  2,  1878. 
«  New  York  Medicjal  Journal,  April  30,  1892. 
3  Loo.  cit. 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT  395 

In  the  second  series^  of  107  cured  cases,  mechanical  and  opera- 
tive treatment  was  employed,  although  the  protection  assured 
was  in  many  instances  far  from  efficient.  In  many  of  these  cases 
the  disease  was  in  an  advanced  stage,  and  deformity  was  present 
in  more  than  half  of  the  number  when  treatment  was  begun,  and 
yet  all  of  them  recovered  without  marked  flexion  and  presumably 
without  adduction,  as  this  defonnity  is  not  mentioned. 

No  flexion 47 

Flexion  of  10° 30 

••       of  10-20° 20 

of  20-30° 10 

Perfect  motion  was  retained  in 13 

Good 22 

Limited        "       <•  ••         •• 41 

There  was  anchylosis  in 31 

In  69  cases  the  shortening  was  one  inch  or  less,  35  having  no 
shortening.     In  38  it  was  more  than  one  inch. 

As  has  been  stated,  the  mechanical  treatment  in  these  cases 
was  not  sufficiently  effective  to  prevent  deformity,  and  to  attain 
these  results  osteotomy  with  or  without  division  of  contracted  tis- 
sues was  performed  in  19  cases,  forcible  correction  with  or  without 
tenotomy  in  30  cases,  and  in  4  cases  the  joint  was  excised. 

If  the  joint  has  been  actually  invaded  by  disease  so  that  a  part 
of  its  articulating  surface  has  been  destroyed,  motion  must  be 
impeded  both  in  area  and  quality.  In  such  cases  the  joint  is 
somewhat  weakened,  and  it  is  often  sensitive,  although  in  many 
instances  not  to  the  extent  of  interfering  seriously  with  the  ability 
of  the  patient.  In  this  class  discomfort  in  damp  weather  or  pain 
on  overexertion  is  experienced,  symptoms  similar  to  those  com- 
plained of  by  rheumatic  subjects. 

Simple  shortening,  due  to  retardation  of  growth,  unaccompa- 
nied by  deformity,  is  of  comparatively  little  importance.  Firm 
anchylosis  in  a  symmetrical  position  ensures  a  strong  and  useful 
limb,  the  flexibility  of  the  lumbar  region  compensating  for  the 
loss  of  motion  at  the  joint.  In  such  cases  the  disability  may 
be  very  slight,  and  the  effect  of  the  loss  of  motion  may  be  more 
apparent  in  the  sitting  than  in  the  erect  posture,  for  the  patient 
must,  as  it  were,  sit  upon  his  back,  an  attitude  which  perceptibly 
reduces  the  sitting  height. 

Flexion,  if  it  be  slight,  does  not  cause  disability,  but  flexion 
of  more  than  30  degrees  increases  the  lumbar  lordosis  and  makes 
the  buttock  prominent,  the  deformity  so  characteristic  of  the 
natural  cure  (Fig.  207).     Great  flexion,  for  example,  of  GO  or  90 

1  Gibney,  Waterman,  and  Reynolds,  Trans.  Amer.  Orth.  Assoc,  1S9S,  vol.  xi. 


396  ORTHOPEDIC  SURQEBT 

degrees,  causes  an  exaggerated  lordosis  which  is  almost  alwsay 
a  source  of  pain  or  discomfort  to  a  patient  who  is  obliged  to  stand 
much  of  the  time. 

Abduction  is  of  no  importance  unless  it  is  considerable.  It 
serves  in  most  instances  as  a  compensation  for  actual  shortening 
of  the  limb. 

Adduction,  on  the  other  hand,  wliich  necessitates  an  upward 
tilting  of  the  peh-is  in  order  to  restore  the  parallelism  of  the  limbs, 
is  the  most  disastrous  of  all  the  distortions,  since  it  causes  a  prac- 
tical shortening  often  greater  than  that  due  to  the  destructive 
effects  of  the  disease. 

The  motion  that  is  retained  after  recovery  from  hip  disease  is 
usually  considered  as  the  test  of  successful  treatment.  This  is 
by  no  means  the  fact,  for  in  many  instances  motion  is  preserved 
because  the  joint  is  destroyed  and  because  what  remains  of  the 
upper  extremity  of  the  femur  is  supported  by  the  tissues  on  the 
dorsum  of  the  ilium — a  form  of  pathological  dislocation. 

In  such  cases  deformity  is  almost  always  present,  and  the 
support  is  insecure. 

Deformity  is  far  more  disabling  than  loss  of  motion,  and  the 
best  safeguard  against  final  deformity  is  to  prevent  it  during 
treatment,  and  to  retain  as  far  as  may  be  the  joint  surfaces  in 
proper  relation  to  one  another.  Whatever  motion  is  preserved 
will  then  be  of  service  to  the  patient,  and  if  anchylosis  follows 
the  result  may  still  be  classed  as  good. 

Deformities  of  Other  Parts  Caused  by  Hip  Disease. — Deformities 
of  other  parts  are  sometimes  observed  as  secondary  results  of  hip 
disease,  most  often  in  cases  that  have  not  received  proper  treat- 
ment. In  the  spine  an  exaggerated  lordosis  as  a  compensation 
for  flexion  is  not  uncommon,  and  lateral  curvature  may  follow 
distortion  of  the  pelvis  caused  by  adduction.  In  the  limb  knock- 
knee  may  follow  persistent  adduction  of  the  thigh,  or  it  may  be 
an  effect  of  laxity  of  the  ligaments  without  such  distortion. 
Another  deformity  is  genu  recurvatum.  This  is  apparently  caused 
by  long-continued  disuse  of  the  limb,  and  by  the  use  of  apparatus 
in  which  the  knee  has  not  been  properly  supported.  If  is  sup- 
posed to  be  one  of  the  effects  of  traction,  but  it  is  also  observed 
in  cases  in  which  traction  has  never  been  employed.  In  cases  in 
which  the  muscular  atrophy  that  follows  limited  motion  and  long- 
continued  disuse  is  great,  laxity  of  the  ligaments  of  the  knee-joint 
is  common,  and  not  infrequently  subluxation  of  the  tibia  also. 
A  slight  degree  of  equinu^s  with  accompanying  exaggeration  of  the 


TUBERCULOUS  DISEASE  OF  THE  HIP-JOINT         397 

arch  is  not  uncommon  among  patients  who  have  been  treated  by 
the  traction  apparatus,  in  which  the  foot  is  pendent  and  in  which 
the  toes  are  often  inclined  downward  to  guide  the  brace  in  walking. 
Practically  speaking,  all  these  secondary  deformities  may  be 
avoided  by  proper  supervision  of  the  patient  during  the  period 
of  treatment. 

As  a  rule,  patients  who  have  recovered  from  hip  disease  finally 
discard  all  apparatus,  or  at  most  use  only  a  cane  as  a  support, 
and  many  prefer  to  walk  habitually  on  the  toe  rather  than  to 
equalize  the  length  of  the  limbs  by  a  high  shoe. 

By  far  the  larger  number  of  this  class,  having  accommodated 
themselves  to  whatever  weakness  and  distortion  may  be  present, 
are  able  to  undertake  the  ordinary  occupations  of  life.  Of  the 
patients  cured  at  the  New  York  Orthopedic  Dispensary  and 
Hospital  in  the  report  already  referred  to,  in  whom  the  final 
results  as  regards  motion  and  symmetry  were  certainly  not  above 
the  average,  it  is  stated  that  there  was  not  a  single  individual 
who  was  incapacitated  from  doing  a  full  day's  work  at  his  or  her 
trade  or  occupation.  None  used  crutches  and  but  one  used  a 
cane. 


I"  =  +  25  per  cent. 


CHAPTER   VIII. 

-\OX-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT. 

The  relative  frequency  and  importance  of  the  various  affec- 
tions of  the  hip-joint  that  cause  disabihty  are  indicated  by  the 
following  statistics  of  Koenig's^  clinic  at  Gottingen: 

Tuberculous  disease 568     =       75  per  cent. 

Infectious  arthritis  following  typhoid  fever: 

Scarlatina  and  the  like 110") 

Gonorrhoeal  arthritis 30 

Arthritis  deformans 22 

Injuries 11 

Contractions,  cause  unknown 6 

Coxa  vara 5 

Tumors 2 

Pyaemic  suppuration 3 . 

757 

Several  of  the  affections  enumerated  are  very  uncommon  in 
childhood,  while  injury  and  coxa  vara  are  relatively  more  im- 
portant. Coxa  vara  and  fracture  of  the  neck  of  the  femur  in 
early  life  are  considered  in  Chapter  XV. 

Traumatisms  at  the  Hip-joint. 

It  is  probable  that  injury  at  the  hip-joint,  caused  by  falls  or 
strains,  may  induce  congestion  about  the  epiphyseal  cartilage  of 
the  head  of  the  femur.  In  this  class  of  cases  there  is  usually 
discomfort  at  night  after  overexertion,  "growing  pain,"  and 
there  may  be  a  limp  and  restriction  of  motion.  These  symptoms 
may  disappear  in  a  few  days  or  they  may  recur  from  time  to 
time.  If  the  injury  is  more  severe  there  may  be  local  sensitiveness 
and  even  swelling — synovitis.  This  congestion,  with  the  lessened 
local  resistance  induced  by  it,  may  be  a  predisposing  cause  of 
tuberculous  disease.  It  is  probable,  also,  that  cases  of  this  type 
are  sometimes  mistaken  for  liip  disease  and  go  to  swell  the  number 
of  perfect  functional  results  that  are  attained  by  one  or  another 
system  of  treatment. 

Treatment. — All  cases  of  this  class  require  careful  treatment 
and  supervision.     Strains  or  other  injuries  in  young  children  are 

1  Dan  Iloeftgelcnk,  IJeilin,  1902. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT    399 

best  treated  by  a  supporting  bandage  and  by  rest  in  bed  until 
the  symptoms  disappear.  If  the  sensitive  condition  persists, 
protective  treatment  by  a  brace,  preferably  the  ordinary  traction 
hip  splint,  or  by  a  short  plaster  bandage,  should  be  employed, 
the  diagnosis  being  reserved  initil  it  is  made  clear  by  the  progress 
of  the  case.  Chronic  syno\dtis  of  the  hip-joint,  especially  in 
the  adolescent  or  adult,  unless  it  is  a  result  of  severe  injury,  is 
usually  tuberculous  in   character. 

Fracture  of  the  neck  of  the  femur,  epiphyseal  separation,  and 
coxa  vara  are  considered  in  another  section. 

Acute  Infectious  Arthritis — Acute  Epiphysitis  at  the  Hip-joint. 

Acute  epiphysitis,  caused  by  infection  with  pyogenic  germs,  is 
not  uncommon  in  infancy  and  early  childhood,  and  it  often  passes 
as  a  form  of  acute  tuberculous  disease.  Of  fifty-two  cases  in 
which  but  a  single  joint  was  involved  the  hip  was  affected  in 
twenty-six.^  In  some  instances  it  is  induced  or  favored  by  in- 
jury, in  others  it  is  secondary  to  an  infected  wound,  and  it  may 
follow  pneumonia  or  one  of  the  exanthemata. 

Symptoms. — ^The  symptoms  are  of  sudden  onset,  accompanied 
usually  by  high  fever  and  prostration.  The  hip  becomes  swollen, 
hot,  and  sensitive  both  to  motion  and  pressure. 

Treatment. — The  treatment  is  early  and  free  incision  and 
efficient  drainage,  the  limb  being  afterward  supported  by  some 
form  of  splint.  The  suppuration  ordinarily  persists  for  several 
months;  the  epiphysis  is  usually  destroyed  in  whole  or  in  part, 
and  in  consequence  the  joint  becomes  somewhat  loose  and  flail-like 
(Fig.  266).  Many  of  these  cases  seen  in  later  years,  but  for 
the  history  and  the  scars  about  the  joint,  might  be  mistaken  for 
congenital  dislocation.  In  certain  instances  the  symptoms  are 
less  acute  and  the  diagnosis  from  tuberculous  disease  can  be 
made  positively  only  after  a  bacteriological  examination  of  the 
fluid  that  may  be  removed  from  the  joint  by  aspiraton. 

In  the  class  of  cases  in  which  the  disease  is  confined  to  one 
joint  and  in  which  the  shaft  of  the  bone  is  not  involved,  the  prog- 
nosis is  good  if  the  pus  is  thoroughly  evacuated.  In  twelve 
cases  treated  at  the  Hospital  for  Ruptured  and  Crippled  there 
were  three  deaths.^  The  prognosis  as  to  function  under  these 
conditions  is  much  better  than  in  tuberculous  disease. 

1  Townseiid,  American  Journal  of  the  Medical  Sciences,  January,  1890. 
-  Townsend,  loc.  cit. 


400  ORTHOPEDIC  SURGERY 

After  recovery  the  joint  should  be  supported  for  a  time  to 
prevent  upward  displacement.  If  the  head  of  the  femur  has 
been  destroyed  there  is  usually  upward  and  backward  displace- 
ment. This  induces  flexion  and  adduction  of  the  limb  and  great 
disability.  In  such  cases  one  should,  under  ancTsthesia,  force  the 
femur  forward  to  the  neighborhood  of  the  anterior  superior  spine 
and  to  fix  it  there  for  a  long  period  by  the  application  of  a  Lorenz 
spica  bandage  applied  wath  the  limb  in  an  attitude  of  abduction 
and  hyperextension.  The  operation  is  in  detail  similar  to  the 
Lorenz  method  for  replacing  the  congenital  dislocation.  (See 
Congenital  Dislocation  of  the  Hip.) 

Subacute  Arthritis. 

In  the  forms  of  arthritis  that  may  complicate  infectious  dis- 
eases several  joints  are  usually  involved,  and  the  affection  is 
often  subacute  in  character. 

Undoubtedly  there  are  mild  cases  of  infection  at  the  hip-joint 
terminating  in  partial  or  complete  recovery  without  operation. 
In  such  cases,  which  are  usually  classed  as  rheumatism,  there  is 
usually  some  infiltration  about  the  hip,  flexion  deformity,  limita- 
tion of  motion,  and  pain  or  discomfort  referred  to  the  affected  joint. 
A  satisfactory  treatment  is  the  application  of  ichthyol  omtment 
in  a  strength  of  about  25  per  cent.,  the  joint  being  fixed  by  a 
posterior  mre  splint  or  light  Thomas  hip  brace. 

Spontaneous  Dislocation  of  the  Hip-joint. 

If  the  hip-joint  becomes  distended  with  fluid  the  capsule  may 
be  ruptured  and  sudden  displacement  may  occur. 

Degez^  has  collected  from  literature  seventy-nine  cases  of  this 
character.  The  displacement  occurred  in  the  course  of  the  fol- 
lowing diseases: 

Typhoid  fever 32 

Rheumatiam 24 

Scarlatina 13 

Variola 3 

Gonorrhoea!  arthritis 3 

La  grippe     ...            2 

Erysipelas 1 

Eruptive  fever 1 

Such  acclflcnts^  may  bo  guarded  against  by  preventing  flexion 
and  adduction  of  the  lirnl)  and  by  evacuation  of  the  fluid  that 

•  Itevuc  <l'()rthor)(;die,  .January  1,  1899. 

*  Graff,    Deutsche  Zeits.  f.  Chir.,  February,  1902. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT    401 


Fig.  266 


distends  the  joint.  The  femur  should  be  rephiced  as  soon  as 
possible  before  it  has  become  fixed  by  adhesions  and  contrac- 
tions. Even  in  this  class  of  cases,  in  which  treatment  has  been 
delayed  for  months,  by  means  of  preliminary  traction  and  by 
the  use  of  manual  force,  as  in  the  reduction  of  congenital  disloca- 
tion, one  may  succeed  in  replacing  the  femur.  In  cases  of  long 
standing  the  acetabulum  is  filled  with 
new  material,  which  must  be  removed 
by  the  open  method  before  replacement 
is  possible.  As  an  alternative  operation 
one  may  force  the  head  of  the  femur  into 
the  anterior  position  and  fix  the  limb,  for 
several  months,  in  the  attitude  of  exten- 
sion and  adduction.  If  the  outward  rota- 
tion of  the  foot  is  excessive,  or  if  a  ten- 
dency toward  adduction  persists,  a  sec- 
ondary osteotomy  of  the  shaft  below  the 
trochanter  minor  may  be  performed. 
However  early  reduction  is  accomplished , 
limitation  of  motion  is  to  be  expected,  and 
in  many  instances  absolute  anchylosis. 
On  this  account  the  limb  should  be  sup- 
ported for  a  time  in  proper  position  in 
order  to  prevent  deformity. 

Gonorrhoeal  Arthritis. 

Gonorrhoeal  arthritis  of  this  joint  is  an 
affection  not  uncommon  in  adult  life,  and 
in  its  s_yTnptoms  and  effects  it  may  re- 
semble tuberculous  disease  or  perhaps 
more  closely  osteoarthritis.  The  treat- 
ment of  infectious  arthritis  in  general  is 
discussed  elsewhere.  Deformity  should 
be  corrected  by  rest  in  bed  with  traction, 
and  protective  treatment  should  be  em- 
ployed while  the  sensitiveness  persists. 
The  short  spica  plaster  bandage,  if  properly  applied,  is  a  satisfac- 
tory support. 

Extra-articular  Disease. 

Occasionally  tuberculous  disease,  or  other  form  of  destructive 
ostitis,  may  begin  in  the  neighborhood  of  the  trochanter  major. 

20 


The  later  effect  of  acute  epi- 
physitis of  the  right  hip  at  three 
months  of  age.  The  scar  is 
shown. 


402  ORTHOPEDIC  SUROERY 

The  symptoms  are  local  pain,  sensitiveness,  and  swelling  of  the 
soft  parts.  Later  thickening  and  irregularity  of  the  underlying 
bone  become  e^ddent. 

The  symptoms  are  limp  and  discomfort.  If  the  disease  in- 
volves the  capsule  or  is  sufficiently  acute  to  cause  sympathetic 
congestion  of -the  joint,  there  may  be  limitation  of  motion;  but, 
as  a  rule,  this  is  slight  or  absent.  In  many  instances  the  focus 
in  the  bone  may  be  demonstrated  by  an  .r-ray  negative.  When 
the  disease  is  tuberculous  or  of  the  subacute  type,  abscess  in  the 
trochanteric  or  gluteal  region  may  be  the  first  indication  of  disease. 

The  treatment  is  prompt  removal  of  the  focus  of  disease  before 
ihe  joint  or  the  shaft  of  the  femur  has  become  involved. 

Disease  of  the  pehdc  bones  in  the  neighborhood  of  the  joint 
may  simulate  hip  disease.  The  diagnosis  is  made  by  the  local 
swelling  and  sensitiveness,  and  by  the  freedom  of  motion  in  the 
directions  not  restrained  by  sensitive  tissues  that  are  involved 
in  the  disease. 

Gluteal  Bursitis. — An  enlargement  of  one  of  the  bursfe  lying 
beneath  the  gluteal  muscles  may  cause  a  rounded,  fluctuating 
swelling  in  the  buttock.  It  may  be  sensitive  to  pressure  and  it 
usually  causes  a  limp  and  some  discomfort  on  motion,  dependent 
upon  the  degree  of  inflammation  that  may  be  present.  Occasion- 
ally the  bursitis  may  be  caused  by  injury,  but  in  most  instances 
it  is  the  result  of  tuberculous  infection.  The  bursa  may  com- 
municate with  a  diseased  hip-joint,  but  usually  it  is  a  distinct 
and  primary  affection. 

Iliopsoas  Bursitis.— The  iliopsoas  bursa  lies  in  front  of  the 
capsule  of  the  hip-joint,  extending  from  the  trochanter  minor  to 
and  sometimes  over  the  brim  of  the  pelvis.  Not  infrecjuently 
it  communicates  with  the  joint.  If  the  bursa  is  enlarged  it  forms 
a  swelling  in  Scarpa's  space  of  a  somewhat  quadrilateral  form. 
Sometimes  a  central  indentation  indicates  the  position  of  the 
iliopsoas  tendon.  This  causes  a  distinct  enlargement  of  the 
upper  and  inner  aspect  of  the  thigh.  It  is  usually  accompanied 
by  slight  flexion,  abduction,  and  outward  rotation  of  the  limb, 
an  attitude  that  relieves  the  tension  on  the  sensitive  part. 
Zuelzer  has  collected  from  literature  forty-five  cases  of  gluteal 
and  fifteen  of  iliopsoas  bursitis.  This  illustrates  the  relative 
frec|Mency  of  the  two  aifections.^ 

Simple  bursitis  may  be  distinguished  from  disease  of  the  joint 
by  the   absence   of  characteristic   muscular  spasm   and   general 

'  Deutsche  Zeits.  f.  (^hir.,  Bd.  i.,  U.  1  und  2. 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT    403 

limitation  of  motion.     Acute  inflammation  of  a  bursa   may  simu- 
late local  abscess. 

Treatment. — Chronic  disease  of  bursre  is  usually  tuberculous 
in  character.  Aspiration  and  injection  of  carbolic  acid  or  iodo- 
form emulsion  may  be  employed  as  primary  measures.  As  a 
rule,  however,  incision,  drainage,  or,  if  possible,  removal  of  the 
sac  is  indicated.  According  to  Lund,^  the  iliopsoas  bursa  may 
be  reached  easily  by  a  vertical  incision  between  the  femoral  artery 
and  the  crural  nerve. 

Malignant  Disease  about  the  Hip-joint. 

Carcinoma  of  the  upper  extremity  of  the  femur  is  almost  always 
secondary  to  a  primary  tumor  of  another  part  of  the  body.  Sar- 
coma is  far  less  frecjuent  in  this  situation  than  at  the  knee.  The 
character  of  the  disease  soon  becomes  e^ddent  in  the  general 
enlargement  of  the  upper  extremity  of  the  thigh,  but  in  the  early 
stage  diagnosis  can  be  made  only  by  means  of  the  .r-ray  or  by 
exploratory  incision. 

Cysts  of  the  Femur. 

In  rare  instances  cysts,  caused  apparently  by  congenital  inclusion 
of  a  displaced  portion  of  epiphyseal  cartilage,  may  cause  enlarge- 
ment, weakening,  and  deformity  of  the  upper  extremity  of  the  femur. 
One  case,  in  a  boy  thirteen  years  of  age,  was  treated  at  the  Hospital 
for  Ruptured  and  Crippled.  The  sjTiiptoms  were  discomfort, 
limp,  and  outward  bowing  of  the  upper  third  of  the  femur.  Cure 
followed  its  removal.  Of  24  cases  reported  13  were  of  the  upper 
extremity  of  the  femur,  1  of  the  lower  end,  3  of  the  upper 
extremity  of  the  tibia,  3  of  the  upper  portion  of  the  humerus. 
The  affection  is  usually  discovered  during  the  growing  period, 
injury  being  an  exciting  cause.  In  some  instances  spontaneous 
fracture  occurs." 

Cysts  may  be  caused  also  by  localized  osteomyelitis  of  a  mild 
character. 

Arthritis  Deformans. 

Osteoarthritis  of  the  Hip-joint.— Osteoarthritis  is  not  infre- 
quently confined  to  the  hip-joint.     In  this  form  it  is  practically 

'   Boston  Medical  and  Surgical  Journal,  September  25,  1902. 
-  Mikulicz,  Zeits.  f.  Chir.,  November  19,   1904. 


404  ORTHOPEDIC  SUROERY 

an  affection  of  adult  life  or  old  age  (malum  coxfe  senile).  It  is  far 
more  common  in  males  than  in  females.  It  is  characterized  in 
its  later  stages  by  disappearance  of  the  cartilage  covering  the  head 
of  the  femur  and  by  an  eburnation  and  progressive  destruction,  or 
wearing  away,  of  the  iinderl}-ing  bone  with  formation  of  ecchon- 
droses  about  .the  junction  of  the  femur  with  the  acetabulum, 
which  become  ossified  into  irregular  masses  of  bone.  In  the 
early  stage  of  the  affection  the  fluid  within  the  joint  may  be  in- 
creased in  amount,  but  later  it  is  diminished  in  quantity  and 
changed  in  quality  as  the  synovial  membrane  becomes  trans- 
formed in  part  to  fibrous  tissue.  The  etiology  of  the  affection  is 
discussed  elsewhere.     (See  page  279.) 

Symptoms.— The  early  symptoms  are  usually  subacute  in  char- 
acter. They  are  neuralgic  pain  in  the  limb,  "sciatic  rheumatism," 
stiffness  on  changing  from  rest  to  acti^dty,  and  sensitiveness  to 
direct  pressure  on  the  joint,  so  that  the  patient  often  lies  habitually 
on  the  other  side.  The  movements  of  the  joint  become  somewhat 
restricted,  and  the  patient  notices  that  he  cannot  take  a  long  step 
or  ride  with  comfort.  In  many  instances  creaking  or  grating  in 
the  joint  is  noticeable.  In  advanced  stages  of  the  disease  there  is 
marked  thickening  about  the  trochanter  which  is  usually  displaced 
upward,  owing  to  the  progressive  changes  in  the  head  and  neck  of 
the  femur.  The  limb  is  shortened  and  it  is  often  distorted,  usually 
in  an  attitude  of  flexion  and  adduction,  and  marked  atrophy  is 
apparent,  appearances  that,  but  for  the  history,  might  be  mis- 
taken for  fracture  of  the  neck  of  the  femur.  So  also  in  the  earlier 
period  of  the  disease  the  limp,  the  pain,  and  restriction  of  motion 
with  the  attendant  atrophy  may  simulate  very  closely  tuberculous 
disease  of  a  subacute  type. 

The  progress  of  the  disease  may  be  slow  or  it  may  be  rapid. 
It  depends  in  great  degree  upon  the  strain  to  which  the  part  is 
subjected.     In  this  it  resembles  tuberculous  disease. 

Treatment. — In  the  class  of  cases  in  which  the  disease  is  con- 
fined to  a  single  joint  one  may  hope  to  check  the  progress  of  the 
destructive  process  by  lessening  the  strain  upon  the  joint  by 
regulation  of  the  patient's  habits  and  occupation,  and  to  improve 
the  nutrition  of  the  part  by  massage  and  local  stimulants. 
Passive  motion  in  the  directions  of  abduction  and  extension,  for 
the  purpose  of  preventing  secondary  contraction  of  the  muscles, 
is  of  service  also. 

If  deformity  is  present  it  should  be  reduced  by  traction  and 
rest  in  bed.     Afterward  the  symptoms  may  be  relieved  by  the 


NON-TUBERCULOUS  AFFECTIONS  OF  THE  HIP-JOINT     405 

use  of  a  hip  brace  (Fig.  252)  that  will  remove  the  weight  and 
limit  the  range  of  motion,  or  a  support  of  the  character  of  a  Lorenz 
spica  of  plaster,  leather,  or  other  material  may  be  used.  In 
extreme  cases  resection  of  the  upper  extremity  of  the  femur  might 
be  advisable.  Lorenz  states  that  he  has  treated  cases  satisfac- 
torily by  inducing  anterior  transposition  of  the  head  of  the  femur 
and  fixing  the  limb  for  a  time  in  an  attitude  of  extension  and 
abduction.  In  most  cases  neither  the  operative  nor  the  brace  treat- 
ment is  feasible,  but  the  use  of  a  firm  flannel  spica  bandage  or 
similar  support,  combined  with  the  application  of  cauterj^  from 
time  to  time,  adds  to  the  comfort  of  the  patient. 


CHAPTER    IX 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT. 

Synonyms. — White  swelling,  tumor   albiis. 

Tuberculous  disease  of  the  knee-joint  is  next  in  frequency  and 
importance  to  that  of  the  hip.  It  is,  however,  far  less  dangerous 
to  life,  and  the  prognosis,  as  regards  function,  is  much  better  than 
in  the  former  affection.  This  is  explained  by  the  simplicity  of 
the  joint  and  by  its  situation  at  a  distance  from  the  trunk,  at  the 
junction  of  two  levers  of  nearly  equal  length  and  size.  As  the 
problem  of  protection  by  mechanical  means  is  comparatively 
simple  it  is  more  often  applied,  and  in  proportion  to  its  efficiency 
the  injury  is  lessened  and  the  tendency  to  deformity  is  checked. 

Fig.  267 


Section  of  knee-joint  at  the  age  of  eight  years, 
showing  the  epiphyses  of  the  femur  and  tibia  and  their 
relation  to  the  capsule.  (Krause.)  The  centres  of 
ossification  in  the  epiphyses  of  the  femur  and  tibia  are 
present  at  birth.  Ossification  is  completed  in  each  at 
about  the  twentieth  year. 

The  range  of  motion  is  from  slightly  more  than 
complete  extension  t(j  about  50  to  60  degrees.  In 
complete  extension  the  tibia  is  rotated  outward  on  the 
femur.  In  midflexion  the  laxity  of  the  ligaments  per- 
mits a  range  of  inward  and  outward  rotation  of  about 
25  degrees. 


Pathology. — The  disease  may  begin  in  the  epiphysis  of  the 
femur  or  in  that  of  the  tibia,  occasionally  in  the  patella  or  in  the 
head  of  the  fibula,  or  primarily  in  the  synovial  membrane. 

In  .547  cases, ^  about  two-thirds  of  which  were  in  adults,  treated 
at  Koenig's  clinic  at  Gottingen  by  operative  procedures  which 
permittee]  inspection  of  the  joint,  281  (51.4  per  cent.)  were  appa- 
rently examples  of  primary  osteal  disease;  266  (48.6  per  cent.) 
were   primarily   synovial.     The   focus   was   in    the   femur   in    93 


'    Die  Speciellc  'riiberculose   dcr    Kriockcii   uiid   (Jeleiike,   Uerliii,   1890. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        407 

instances  (33.1  per  cent.),  in  the  tibia  in  107  (3<S.l  per  cent.j,  in 
the  patella  in  33  (11.7  per  cent.),  and  in  more  than  bone  in  48 
(17.1   per  cent.). 

The  examination  of  a  joint  permitted  by  arthrectomy  or  excision 
cannot  be  sufficiently  thorough  to  exclude  disease  of  the  bone  and 
to  establish  the  diagnosis  of  primary  disease  of  the  synovial  mem- 
brane, but  in  92  instances  the  opportunity  was  offered  by  ampu- 
tation at  the  thigh,  80  of  the  patients  being  adults.  This  examina- 
tion,  presumably  thorough,   showed   the   primary  disease   to   be 

Fif;.   268 


Acute   tuberculous   arthritis   of   the   knee. 


of  the  bone  in  50  cases,  while  in  35  the  synovial  membrane 
was  apparently  the  seat  of  the  primary  affection.  In  17  of 
the  50  cases  in  which  the  disease  was  osteal,  the  focus  was  in 
the  femur;  in  7  it  was  in  the  internal  condyle,  in  0  in  the 
external  condyle,  and  it  was  in  other  situations  in  4  cases.  In 
17  the  primary  disease  was  of  the  tibia;  in  5  of  the  interual  tuber- 
osity; in  5  of  the  external  tuberosity;  in  other  situations  7.     In 


408 


OR  THOPEDIC  S  UR  G  ER  Y 


Fig.   269 


5  instances  tlie  primary  disease  was  of  the  patella,  and  more 
than  one  bone  was  involved  in  11  cases.  Nichols^  states  that  he 
has  examined  120  tuberculous  joints  of  adults  and  children,  after 
excision  or  amputation,  or  at  autopsy,  and  in  every  instance 
primary  foci  in  the  bone  were  discovered.  He  believes  primary 
disease  of  the  s}Tiovial  membrane  to  be  very  uncommon,  and 
asserts  that  examinations  are  of  no  particular  value  as  establishing 
the  absence  of  primary  osteal  disease  unless  the  bones  are  sawed 

into  thin  sections.  This  is  the  view 
generally  held  in  this  country,  that  in 
the  great  majority  of  cases  the  disease 
of  the  bone  precedes  the  disease  in 
the  interior  of  the  joint.  From  the 
clinical  standpoint,  however,  one  re- 
cognizes two  distinct  types  of  tuber- 
culous disease:  one  beginning  as  a 
chronic  synovitis  of  which  the  early 
symptoms  are  subacute,  a  type  more 
often  seen  in  adults  (Fig.  269);  and 
the  more  common  class,  in  which  the 
symptoms  of  pain,  muscular  spasm, 
and  deformity  seem  to  indicate 
clearly  primary  disease  of  the  bone. 
The  proximity  of  the  active  disease 
in  the  neighborliood  of  the  joint  sets 
up  a  sympathetic  hypera?mia  within 
it,  and  an  accompanying  synovitis. 
If  tlie  disease  is  progressive  the  syno- 
vial membrane  becomes  thickened 
and  adhesions  form  between  its  folds 
that  gradually  lessen  the  capacity  of 
the  joint  and  diminish  its  mobility. 
When  perforation  takes  place  the 
granulation  tissue  spreads  over  the  surface  of  the  cartilages,  destroy- 
ing them  in  its  progress  and  eroding  the  underlying  bone;  or  if  the 
joint  is  filled  with  tuberculous  fluid  the  cartilage  may  be  macerated 
and  separated  in  necrotic  shreds.  The  direct  destructive  effects 
of  the  (Hsease  are  increased  by  pressure  and  friction  if  the  joint  is 
not  protected  by  meclianical  means.  TJie  hypertrophied  synovial 
menibrane  and  the  thickened  and  diseased  capsule  explain  the 
peculiar  elastic  resistance  on  palpation  called  pseudofluctuation. 


TubercLil(,(i.^  di.seu.sc  of  the  kuee  in  an 
afiult.     The  synovial  type. 


'  Transactions  American  Ortliopedic  AHsocialioii,  vol.  xi. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        409 

In  more  advanced  cases  there  is  also  a  reactive  inflammation  in 
the  overlying  tissues,  accompanied  by  a  formation  of  fibrous 
tissue  that  involves  the  tendons  and  muscles.  These  changes 
within  and  without  the  joint  cause  the  firm,  resistant  tumor 
characteristic  of  "wjiite  swelling." 

Etiology. -^The  etiology  of  tuberculous  disease  has  been  dis- 
cussed in  Chapters  V.  and  VII. 

Statistics. — Tuberculosis  of  the  knee-joint  is  essentially  a  dis- 
ease of  early  life,  although  it  is  less  strictly  confined  to  childl  ood 
than  is  disease  of  the  spine  or  hip.  Sex  exercises  but  httle  influ- 
ence, and  the  two  sides  are  affected  in  nearly  equal  numbers. 
These  points  are  illustrated  by  tlie  following  table  of  1000  con- 
secutive cases  treated  at  the  Hospital  for  Ruptured  and  Crippled.^ 


Age  at  Incipiency  of  Knee-joint  Disease. 


1  year  or  less 

2  years  old   . 
3 


4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 


25         23  years  old 12 

8 

3 

2 

4 

5 

7 

1 

1 

2 

1 

1 

4 

0 

2 

1 

1 

1 

1 

1 


45 

24 

91 

25 

64 

26 

84 

27 

75 

28 

66 

29 

74 

30 

65 

31 

60 

32 

46 

33 

20 

34 

19 

35 

17 

36 

12 

37 

10 

38 

20 

39 

8 

40 

8 

41 

8 

50 

12 
13 


Males 512 

Females 488 


Right 
Left 


1000 

.   485 
.    515 


Symptoms. — The  general  characteristics  of  tuberculosis  have 
been  described  in  the  chapters  on  Pott's  disease  and  hip  disease. 
In  the  description  of  these  affections,  however,  but  little  stress 
was  laid  on  local  sensitiveness  and  local  swelling,  because  the 
diseased  parts  lie  at  a  distance  from  the  surface  and  are  concealed 
by  the  muscles  and  other  tissues.  At  the  knee,  on  the  other 
hand,  the  joint  is  superficial,  and  even  slight  effusion  changes, 
to  a  perceptible  degree,  its  contour.     If  the  disease  is  progres- 

'  These  statistics,  together  with  those  of  tuberculous  disease  of  the  joints,  other  than  of 
the  hip,  were  collected  for  me  by  Drs.  F.  C.  Bradner,  S.  E.  Sprague,  E.  L.  Barnett,  and 
S.  W.  Stone,  house  officers  at  the  hospital,  1900-1901. 


410 


ORTHOPEDIC  SURGEJ^ 


sive,  sensitiveness  to  pressure,  elevation  of  the  local  temperature, 
and  infiltration  or  thicken'ng  of  the  tissues  are  usually  present. 

Even  when  the  patients  are  seen  at  a  comparatively  early  stage 
in  the  course  of  the  disease  the  history  of  the  affection  will  almost 
always  show  that  it  is  chronic  and  progressive  in  character.  The 
importance  of  ■  establishing  this  fact  has  been  mentioned  in  the 
consideration  of  hip  disease,  and  it  may  be  stated  again  that  a 
chronic  painful  disease  of  a  single  joint,  accompanied  by  a  tendency 
to  deformity,  is,  in  childhood,  almost  always  tuberculous  in 
character. 

The  symptoms  of  tuberculous  disease  may  be  classified  as 
limp,  pain,  local  heat,  sensitiveness  and  swelling,  muscular  spasm 
and  limitation  of  motion,  distortion  and  atrophy. 

Fig.   270 


Flexion  deformity  at  the  knee-joint,  with  slight  subluxation  of  the  tibia. 

On  physical  examination  one  will  note  the  character  of  the 
limp  and  the  slight  flexion  of  the  limb  that  usually  accompanies 
it.  The  joint  is,  as  a  rule,  somewhat  enlarged,  the  normal 
depressions  about  the  patella  and  the  prominence  of  the  component 
bones  being  less  accentuated  than  on  the  opposite  side.  There  is 
usually  slight  local  elevation  of  temperature  and  sensiti  >^eness  to 
pressure,  varying  in  degree  with  the  character  of  the  disease. 
In  certain  cases  a  degree  of  effusion  is  present,  sufficient  to  be 
ola.ssed  as  synovitis,  but  in  most  instances  the  swelling  is  due,  in 
great  part,  to  the  hypera>mia  and  thickening  of  the  synovial 
membrane  and  the  capsule,  wliich  gives  the  sensation  of  elastic 
resistance  rather  than  of  actual   fluctuation. 

The  most  important  diagnostic  sign  is  limitation  of  the  range 
of  motion  caused  by  muscular  spasm.  The  normal  range  is  from 
complete  extension,  180  degrees,  to  a  degree  of  flexion,  limited  by 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT       411 

the  apposition  of  the  calf  and  the  posterior  surface  of  the  thigh. 
Even  in  the  early  stage  of  disease  slight  limitation  of  complete 
extension  is  present,  due  to  reflex  muscular  spasm,  and  usually  a 
corresponding  limitation  of  the  complete  flexion.  On  sudden 
movements  the  characteristic  reflex  contraction  of  the  muscles  is 
apparent.  In  most  cases  this  limitation  of  motion  and  consequent 
flexion  deformity  is  well-marked  on  the  first  examination. 
Atrophy  of  the  muscles  of  the  thigh  and  calf,  dependent  upon 
the  duration  of  the  disease  and  upon  the  interference  with  func- 
tion, is  present,  and  this  atrophy  is  more  noticeable  because  of 
the  enlargement  of  the  knee. 

Fio.   271 


After  forcible  correction,  showing  the  increase  of  the  posterior  displacement. 
Drawings  from  the  x-ray  photographs  of  an  actual  case. 

In  certain  cases,  more  often  seen  in  infancy  and  early  child- 
hood, the  symptoms  are  more  acute  and  the  progress  of  tlie 
disease  is  so  rapid  that  it  may  simulate  an  infectious  epiphysitis 
(Fig.  268). 

In  another  type,  apparently  a  primary  disease  of  the  synovial 
membrane,  more  common  in  adults,  the  early  symptoms  are 
very  similar  to  those  of  simple  chronic  synovitis.  The  joint  is 
swollen  by  a  distention  of  the  capsule,  pain  is  not  troublesome 
except  on  jars  or  sudden  twists  of  the  limb,  and  muscular  spasm 
and  limitation  of  motion  are  evident  only  after  a  careful  exami- 
nation. In  this  class,  months  or  years  may  pass  before  the 
symptoms  become  as  disabling  as  in  the  osteal  type  of  the  disease. 

Primary  and  Secondary  Distortions  of  Knee-joint  Disease. — At  the 
hip-joint,  in  which  the  range  of  motion  is  extensive,  tlie  deformities 
resulting  from  disease  are  somewhat  complex,  causing,  for  example, 
apparent  shortening  or  lengthening,  according  as  the  limb  is  ad- 
ducted  or  abducted.  But  the  movements  that  the  knee-joint  per- 
mits are  much  simpler,  and  the  primary  distortion  is  simply  flexion. 
Complete  extension  of  tlie  limb,  the  hmit  of  normal   motion  in 


412  ORTHOPEDIC  SURGERY 

that  direction,  brings  the  joint  surfaces  into  close  apposition; 
the  hgaments  are  tlien  tense  and  no  lateral  motion  is  permitted. 
This  is  tlie  attitude  in  wliich  the  greatest  efficiency  of  the  limb 
for  weight  bearing  is  assured.  ^ATien  the  ability  of  the  knee  for 
earning  out  its  normal  weight-bearing  function  is  lessened  by 
disease  which  makes  the  parts  sensitive  to  pressure  and  strain, 
the  range  of  extension  is  lessened  and  the  limb  is  persistently 
flexed  to  a  greater  or  less  degree,  corresponding  to  the  sensitive- 
ness of  tlie  joint.  The  agents  that  adapt  the  limb  to  the  habitual 
attitudes  are  the  muscles  under  the  control  of  the  nervous  system. 
In  this  sense  the  primary  distortions  are  due  to  muscular  action, 
but  it  is  certainly  not  true  that  these  muscles  antagonize  one 
another,  and  tliat  the  stronger  overcoming  the  weaker  cause 
the  deformity,  since  the  extensors  at  tliis  joint  are  stronger  than 
the  flexors,  and  since  flexion  is  the  primary  deformity  at  every 
joint  which  is  diseased  without  regard  to  the  relative  strength 
of  the  opposing  muscular  groups. 

In  disease  at  the  knee-joint,  as  at  other  joints,  the  extremes  of 
motion  in  every  direction  that  the  joint  permits  are  limited  by 
muscular  spasm,  but  limitation  of  extension,  which  is  so  essential 
to  normal  use,  is  at  once  evident,  while  limitation  of  flexion,  the 
extreme  of  which  is  unessential,  is  only  apparent  on  examination, 
and  it  may  be  absent  even.  Flexion  is,  then,  the  primary  distortion 
at  tlie  knee,  and  other  deformities  may  be  classed  as  secondary. 

Secondary  Deformities. — Of  these  the  most  common  is  outward 
rotation  of  the  tibia  upon  the  femur.  When  the  limb  is  fully 
extended  the  tibia  is  fixed,  but  when  it  is  flexed  lateral  motion  is 
possible,  and  in  the  attitude  of  flexion  the  traction  of  the  biceps 
upon  the  head  of  the  fibula  tends  to  rotate  it  upon  the  femur. 
Tliis  deformity  is  also  favored  by  the  use  of  the  limb  in  the  atti- 
tude of  outward  rotation,  which  is  always  assumed  when  the  weak- 
ness or  stiffness  of  the  knee-joint  is  present,  and  by  the  secondary 
knock-knee  that  often  accompanies  the  disease. 

Subluxation  or  backward  displacement  of  the  tibia  upon  the 
femur  is  another  secondary  deformity.  When  the  leg  is  flexed 
upon  the  thigli  tlie  articulating  surface  of  the  tibia  glides  back- 
ward upon  the  condyles  of  the  femur.  Here  it  becomes  fixed  by 
muscular  contraction,  and  later  by  the  secondary  changes  within 
the  joint.  If  muscular  spasm  is  extreme,  tliis  alone  may  cause 
the  subluxation;  but  there  are  other  factors:  one  is  the  destruc- 
tive action  of  the  flisease,  which  is  usually  most  marked  at  the 
point  at  which  the  bones  are  in  contact,  and  the  other  is  the  leverage 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT 


413 


exerted  upon  the  joint.  This  is  exempUfied  by  the  increase  of 
the  displacement  that  is  often  observed  when  an  attempt  is  made 
to  straighten  the  liml)  by  force,  against  the  resistance  offered  by 
the  contracted  tissues  on  the  flexor  aspect.     The  same  leverage, 


Fig.    272 


Untreated  disease  of  the  knee-joint  involving  the  shaft  of  the  femur,  illustrating  the 
hypertrophy  of  the  condyles  of  the  femur,  the  subluxation  and  outward  rotation  of  the 
tibia,  the  atrophy  and  the  characteristic  deformity. 

in  slighter  degree,  is  exerted  when  the  weigiit  of  the  distorted 
limb  is  supported  on  the  heel  in  the  recumbent  posture,  or  when 
the  limb  is  extended  in  the  act  of  walking,  or  if  the  upper  extremity 
of  the  tibia  is  not  supported  during  tiie  period  of  treatment  by 
apparatus  (Fig.  271). 


414  OR  TH  OPE  Die  SURGERY 

Knock-kiiee  (genu  valgum)  is  another  secondary  deformity. 
Tiiis  is  explained  in  certain  instances  by  the  hypertrophy  of  the 
internal  condyle  caused  by  disease,  but  it  is  induced  more  directly 
by  the  use  of  the  flexed  and  somewhat  disabled  limb  in  the  pas- 
sive attitude  of  outward  rotation.  Genu  varum  is  uncommon,  and 
it  is  usually  the  result  of  the  destruction  of  a  part  of  the  internal 
condyle  of  the  femur  or  of  the  tibia,  or  of  irregular  epiphyseal 
growth. 

The  character  and  the  relative  frequency  of  the  deformities  are 
indicated  by  the  statistics  of  Koenig's^  clinic,  of  150  cases  of  knee- 
joint  disease  treated  by  arthrectomy,  128  of  these  being  in  children. 
In  94  cases  flexion  was  present;  in  50,  from  a  slight  degree  to  135 
degrees;  in  16,  from  135  degrees  to  90;  in  28,  to  a  right  angle 
or  less.  Together  with  the  flexion  were  combined  other  deformities 
as  follows:  Genu  valgum  in  60  cases;  moderate  in  42;  extreme 
in  18.  Genu  varum  in  1  case.  Subluxation  of  the  tibia  in  20 
cases.     Outward  rotation  of  the  tibia  in  10  cases. 

As  has  been  stated,  the  primary  deformity  of  knee  disease  is 
simple  flexion.  If  the  disease  is  of  an  acute  type  this  flexion 
increases  rapidly.  If  it  is  subacute  in  character,  and  especially 
if  the  clinical  signs  indicate  that  the  disease  is  primarily  of  the 
synoxial  membrane,  the  progress  of  the  deformity  is  slow.  In 
ordinary  cases  secondary  deformities  appear  at  a  later  time  and 
especially  when  the  disease  has  reached  the  destructive  stage; 
and  they  are  most  marked  in  patients  who  have  persistently  used 
the  deformed  limb  without  protection. 

Actual  Shortening  and  Actual  Lengthening.— Retardation  of 
growth  is,  of  course,  not  an  early  symptom  of  disease;  in  fact, 
actual  lengthening  of  the  limb,  due  to  the  irritative  effect  of  the 
disease  upon  the  epiphyseal  cartilage  of  the  femur  or  of  the  tibia, 
is  common.  This  lengthening,  sometimes  to  the  extent  of  an 
inch  or  even  more,  may  persist  throughout  the  entire  course  of 
treatment,  but  after  the  cure  of  the  disease  a  corresponding  retarda- 
tion of  growth  that  will  more  than  equalize  the  length  of  the  limbs 
may  be  expected.  When  the  disease  is  of  the  destructive  type 
the  ultimate  shortening  may  be  considerable;  two  or  more  inches 
is  not  unusual. 

Leu.sden,^  in  33  cases  under  treatment  in  the  clinic  at  Got- 
tingen,  1896-1898,  found  slight  shortening  in  2,  equality  of 
length  in  18,  lengthening  of  the  femur  on  the  diseased  side  in  13. 

In  one  hundred  and  sixteen  cases  of  tuberculous  disease  of  the 

1  Loc.  cit.  -  DeutHclie  ZoitH.  f.  Chir.,  Bd.  li.,  H.   3  unci  4. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT         415 

knee  the  limbs  were  measured  by  Berry  and  Gibney^  with  refer- 
ence to  this  point.  In  72  of  these  there  was  actual  lengthening 
of  the  femur,  from  which  it  may  be  inferred  that  in  at  least  62 
per  cent,  of  the  cases  examined  the  primary  disease  was  of  the 
femur. 

In  17 14   inch. 

"34 K   " 

"15 y^    •' 

"6 1 

72  =  62  per  cent. 

H.  L.  Taylor,^  from  an  examination  of  40  cases  of  tuberculous 
disease  of  the  knee,  concludes  that  the  limb  is  almost  always 
longer  in  the  first  two  years  of  the  disease,  usually  longer  during 
the  second  two  years,  but  usually  shorter  when  the  period  of 
growth  is  completed.  The  lengthening  is  in  most  instances  of 
the  femur. 

Diagnosis. — Tuberculous  disease  is  a  local  destructive  process 
that  is,  as  a  rule,  confined  to  a  single  joint.  This  is  an  important 
point  in  the  differential  diagnosis  from  general  or  constitutional 
affections  like  rheumatism,  rheumatoid  arthritis,  and  the  like,  in 
which  several  joints  are  involved.  The  following  affections  may 
be  considered  in  differential  diagnosis. 

Injury  of  the  Knee. — Strains  of  the  knee  in  childhood  are  often 
followed  by  limp  and  persistent  flexion  and  pain  on  motion.  In 
such  cases  the  onset  is  sudden  and  the  symptoms  usually  disap- 
pear quickly  under  treatment.  Synovitis  of  traumatic  origin  is 
usually  indicative  of  a  more  severe  injury.  When  synovitis  per- 
sists the  diagnosis  may  be  doubtful  because  tuberculous  infection 
may  have  followed  the  original  injury.  This  emphasizes  the 
importance  of  the  careful  treatment  and  continued  observation  of 
injuries  of  this  class,  especially  in  weakly  children. 

Synovitis. — Chronic  synovitis  of  doubtful  origin,  which  shows 
no  tendency  toward  recovery,  is  usually  tuberculous  in  character. 

Hsemarthrosis. — Effusion  of  blood  into  the  knee-joint  may  cause 
inflammatory  symptoms  during  the  stage  of  absorption  and 
organization  of  the  clot  that  resemble  those  of  disease.  The 
sudden  onset  and  the  personal  history  of  the  patient,  who  may  be 
known  as  a  bleeder,  will  explain  the  symptoms.     (See  page  289.) 

Infectious  Arthritis.  Acute  Epiphysitis. — This  is  of  sudden  onset, 
attended  by  the  constitutional  and  local  symptoms  of  acute  infec- 
tion. 

1  American  Journal  of  the  Medical  Sciences,  October,  1S93. 

-  transactions   American   Orthopedic   Association,    1901,   \o\.   xiv. 


41 6  OR  TH  OPE  Die  S  UB  GERY 

Rheumatism. — This,  in  early  childhood,  may  be  confined  to  a 
single  joint,  but  it  is  of  sudden  onset,  it  is  usually  accompanied 
by  constitutional  disturbance,  and  after  a  time  other  joints  become 
inyolyed. 

Rheumatoid  Arthritis.  Osteoarthritis. — Diseases  of  this  char- 
acter, of  the  monarticular  form,  are  more  common  in  adult  life. 
The  symptoms  are  rather  of  the  rheumatic  than  of  the  tuber- 
culous type. 

Charcot's  Disease. — Charcot's  disease  of  the  knee-joint  is  char- 
acterized by  sudden  effusion,  by  rapid  destruction  of  the  joint, 
and  consequently  by  weakness  and  deformity;  but  pain  is  usually 
yery  slight  and  muscular  spasm  is  absent.  The  diagnosis  of  dis- 
ease of  the  spinal  cord  mil  explain  the  condition  of  the  joint. 
(See  page  290.) 

Sarcoma. — Sarcoma,  beginning  in  or  near  the  epiphysis  of  the 
femur  or  of  the  tibia,  may  simulate  tuberculous  disease  very 
closely.  If  the  tumor  is  of  the  periosteal  type,  it  usually  forms 
a  more  localized  and  irregular  swelling  than  could  be  accounted 
for  by  tuberculous  disease.  Central  sarcoma  may  simulate  tuber- 
culous disease  also,  but  the  progress  of  the  tumor  is  more  rapid. 
The  clinical  distinction  between  the  two  is  that  tuberculous  dis- 
ease is  yery  amenable  to  treatment  as  far  as  its  symptoms  are 
concerned,  while  the  progress  of  sarcoma  is  but  little  influenced 
by  treatment.  It  may  be  stated,  howeyer,  that  the  x-ray  is  the 
only  means  of  early  diagnosis,  the  destruction  of  the  substance 
of  the  bone  about  the  tumor  being  much  greater  than  that  caused 
by  the  tuberculous  process. 

Hysterical  Joint. — Some  of  the  symptoms  of  disease  may  be 
simulated  by  hysterical  subjects,  but  there  is  always  an  absence 
of  the  positive  physical  signs  that  invariably  accompany  a  destruc- 
tive disease.  These  and  other  affections  are  described  at  length 
in  the  following  chapters. 

Treatment. — The  treatment  of  tuberculous  disease  of  the  knee 
in  childhood  is  conservative,  operative  intervention  being  simply 
incidental  to  protective  treatment.  In  adult  life,  on  the  other 
hand,  the  radical  removal  of  the  disease  may  be  indicated  as  the 
primary  measure.  The  reasons  for  this  distinction  are  obvious. 
In  childhood  the  duration  of  treatment  is  of  no  particular  impor- 
tance as  compared  with  the  final  functional  result,  but  in  adult 
life  the  shortening  of  the  period  of  disability  and  the  definite 
assurance  of  cure  may  be  of  far  greater  moment  than  the  preser- 
vation of  motion. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        417 

In  childhood,  under  favorable  conditions,  ultimate  recovery,  with 
fair  functional  use  of  the  joint,  may  be  anticipated;  while  a  radical 
operation,  although  it  may  cure  the  patient  in  a  shorter  time, 
takes  away  the  possibility  of  a  cure  with  motion.  In  arlult  life  a 
rigid  limb  is  a  strong,  useful,  if  somewhat  awkward  support,  but 
in  childhood  the  removal  of  portions  of  the  epiphyses  and  of  the 
epiphyseal  cartilages  entails  a  progressive  inequality  in  the  limbs, 
due  to  loss  of  growth,  and  unless  the  limb  is  protected  by  mechani- 
cal means  deformity  is  the  rule,  even  though  the  disease  has  been 
thoroughly  removed.  Thus  the  treatment  of  routine  is,  in  child- 
hood, at  least,  protection;  protection  from  the  traumatism  of 
motion,  from  the  shock  of  impact  with  the  ground,  and  from  the 
pressure  of  muscular  spasm  and  contraction. 

Mechanical  treatment,  which  is  so  difficult  at  the  hip,  is  com- 
paratively easy  at  the  knee,  and,  as  has  been  stated,  the  results 
are  correspondingly  better.  At  the  hip-joint  one  of  the  most 
common  causes  of  shortening  and  deformity  is  upward  displace- 
ment of  the  femur  upon  the  pelvis,  but  at  the  knee,  if  the  limb  is 
supported  in  the  attitude  of  extension,  the  apposition  of  the  broad 
surfaces  of  the  femur  and  the  tibia  prevents  displacement,  while 
muscular  spasm,  a  symptom  whose  intensity  is  in  proportion  to 
the  degree  of  harmful  motion  that  is  permitted,  is  easily  controlled 
by  efficient  splinting. 

Reduction  of  Deformity. — The  first  step  in  treatment  is  the 
reduction  of  deformity  that  may  be  present,  in  order  that  the 
limb,  at  the  beginning  as  well  as  throughout  the  entire  course  of 
treatment,  may  be  in  absolute  normal  position;  and  as  the  chief 
function  of  the  leg  is  to  support  weight  the  proper  attitude  is 
complete  extension.  Whatever  motion  the  patient  retains  will 
then  be  about  the  point  of  greatest  usefulness.  In  the  cases  in 
which  an  opportunity  for  reasonably  early  treatment  is  offered 
the  only  deformity  is  flexion  induced  by  muscular  contraction, 
although  if  it  has  persisted  for  some  time  secondary  retraction  of 
the  muscles  may  be  present.  In  this  class  of  cases  the  spasm, 
and  consequently  the  deformity,  may  be  readily  overcome  by 
placing  the  joint  at  rest. 

The  Plaster  Bandage. — The  most  efficient  splint  for  this  purpose 
in  the  treatment  of  ambulatory  cases  is  a  close-fitting  plaster 
bandage,  applied  from  the  groin  to  the  ankle,  or  better,  to 
include  the  foot,  in  order  to  prevent  oedema  of  the  unsupported 
part,  which  is  common  after  the  first  dressing  and  until  the  circu- 
lation of  the  limb  has  become  adapted  to  the  new   conditions. 

27 


418  ORTHOPEDIC  SUBGEEY 

In  the  application  of  the  banchige  the  bony  prominences  of  the 
knee  and  ankle  are  protected  by  cotton.  A  canton-flannel  bandage 
is  then  applied  smoothly,  and  directly  upon  this  the  light  plaster 
bandage.  At  the  second  application,  at  the  end  of  a  week,  the 
subsidence  of  the  spasm  will  permit  the  straightening  of  the  limb. 
In  cases  of  longer  standing  several  successive  applications  of  the 
bandage  may  be  required,  together  with  manual  extension  during 
the  application;  or  an  anaesthetic  may  be  administered.  Under 
anaesthesia  the  muscular  spasm  relaxes  and  deformity,  even  of  some 
standing,  may  be  reduced  by  traction  and  by  slight  leverage,  the 
head  of  the  tibia  being  supported  and  drawn  forward  by  the 
hands  as  the  deformity  is  gently  reduced. 

Traction. — Deformity  may  be  reduced  also  by  traction  with 
the  weight  and  pulley,  the  leg  being  supported  so  that  no  direct 
leverage  is  exerted  at  the  seat  of  the  disease  (Fig.  273). 

Fig.   273 


Extension  and  counterextension  in  disease  of  the  knee-joint.     (Marsh.) 

Forcible  Correction  by  Reverse  Leverage. — In  the  more  resistant 
ca.ses,  especially  if  accompanied  by  subluxation,  the  following 
method  may  be  employed:  The  patient  is  amiesthetized  and  is 
placed  face  downward  on  a  table,  the  feet  projecting  over  its  end. 

The  body  of  the  patient  is  then  elevatefl  by  means  of  pillows  to 
conform  to  the  deformity — that  is,  the  thigh  of  the  affected  limb 
is  raised  sufficiently  to  allow  the  tibia  to  lie  evenly  upon  its  ante- 
rior border  on  the  table.  The  operator  with  one  hand  holds 
the  head  of  the  tibia  firmly  against  the  table  and  with  the  other 
ma.ssages  the  contracted  tissues  of  the  popliteal  region,  gradually 
exerting  more  downward  pressure  on  the  thigh,  but  never  to  the 
extent  to  lift  the  tibia  horn  the  table;  thus,  further  subluxation 
is  impossible.  As  the  contraction  gives  way  the  pillows  are 
removed.  Usually  tlx;  dcfonnity  may  be  reduced  at  one  sitting, 
but  if  it  is  very  resistant  ccjiii|)let(!  correction  is  not  attempted.  At 
the  r-cnicliisiou  of  the  operation  adhesive^  plaster  straps  for  traction 
and  u  close-fitting  plaster  bandage  are  a})[jlie(l  (Fig.  275). 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT       419 

Rest  in  bed  with  traction  is  enforced  for  a  time,  and  the  ordi- 
nary brace  is  then  employed.  This  is,  in  the  author's  experience, 
the  most  effective  and  satisfactory  method  for  reducing  deformity. 
If  the  contraction  is  of  long  standing  preliminary  division  of  the 
flexor  tendons  may  be  advisable,  but  this  is  not  usually  necessary/ 

Fig.   274 


Tuberculous  disease  of  the  knee  in  an  adult,  with  the  form  of  Billroth  siilint  used 
at  the  Hospital  for  Ruptured  and  Crippled. 

The  Billroth  Splint.— The  Billroth  splint,  as  modified  by  Still- 
man,  is  an  effective  appliance  for  overcoming  resistant  deformity. 
A  thick  pad  of  felt  is  placed  over  the  upper  surface  of  the  condyles 
of  the  femur  and  a  thinner  pad  in  the  popliteal  region  over  the 
upper  border  of  the  tibia.  Other  points  that  may  be  subjected 
to  pressure  are  similarly  protected,  especially  the  tlorsum  of  the 
foot  and  the  perineum.  A  plaster  bandage  is  then  applied  from 
the  groin  to  the  toes,  made  especially  thick  and  strong  in  the 
popliteal  region.  On  either  side  of  the  knee  two  curved,  slottetl 
steel  bars  attached  to  expanded  tin  splints  and  joined  to  one  another 

'  Whitman,  American  Journal  of  the  Medical  Sciences,  May,  1903. 


420 


ORTHOPEDIC  SURGERY 


by  an  adjustable  bolt  are  incorporated  in  it  (Fig.  274).  AVhen 
the  bandage  hardens  it  is  completely  di"\dded  into  two  parts  by 
a  circular  cut  about  the  knee,  and  the  bolts  in  the  slots  are  so 
adjusted  as  to  form  a  hinged  splint,  the  centre  of  motion  being 
somewhat  above  and  in  front  of  the  knee-joint.  Wlien  the  limb 
is  slightly  extended  the  position  of  the  hinges  has  a  tendency  to 
lift  the  tibia  and  to  separate  it  from  the  femur.  This  straightening 
opens  the  cut  in  the  popliteal  region,  which  is  held  open  by  a 
wedge  of  cork.  In  this  manner,  by  the  insertion  of  larger  wedges 
the  limb  is  gradually  straightened  from  day  to  day  until  the  de- 
formity is  overcome,  or  until  a  new  bandage  is  required.  If  the 
pressure  on  the  front  of  the  femur,  when  the  leverage  is  exerted, 
becomes  painful,  a  part  of  the  padding  is  removed. 


Fig.  275 


Illustrating  the  method  of  supporting  the  body  and  fixing  the  tibia  before  straightening 
the  limb.  The  folded  sheet  indicates  the  degree  of  subluxation  present.  In  resistant 
cases  of  this  type  an  assistant  applies  the  pressure  on  the  thigh. 

In  the  treatment  of  older  subjects  greater  force  may  be  em- 
ployed by  means  of  osteoclasts.  One  of  the  best  machines  of  this 
type  is  the  Bradford-Goldthwait  genuclast  (Fig.  276).  The  more 
violent  methods  should  not  be  employed  during  the  active  stages 
of  the  disease;  and  whenever  considerable  force  is  required  in 
young  subjects  the  possibility  of  separating  the  epiphysis  of  the 
femur,  forcing  it  Imckward,  and  thus  pressing  upon  the  popliteal 
ves.sels,  should  be  borne  in  mind. 

Mechanical  Treatment. — The  most  efficient  mechanical  appliance 
for  the  fn;atiii(!iit  of  tuberculous  disease  at  the  knee  is  the  Thomas 
knee  brace.  This  consists  of  two  lateral  uprights  which  support 
the  limb  on  either  side,  terminating  below  the  foot  in  a  crossbar 
shod  with  leather  or  rubl>er,  which  staves  as  a  stilt,  and  above  in 
a  ring  that  fits  the  upper  extremity  of  the  thigh,  and  supjiorts 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        421 


Firj.   270 


the  weight]__of  the  body.  The  brace  is  made  of  iron  wire  from 
three-sixteenths  to  three-eighths  of  an  inch  in  thickness.  The 
ring  is  of  an  irregular  ovoid  shape,  flattened  in  front,  expanded 
behind  and  wider  on  the  inner  than  on  the  outer  side  (Fig.  277). 
This  ring  is  welded  to  the  uprights  at  a  lateral  and  antero- 
posterior inclination.  The  lateral  inclination  forms  an  angle  with 
the  inner  bar  of  135  degrees  (Fig.  279),  the  anteroposterior 
inclination  forms  an  anterior  angle 
of  145  degrees  (Fig.  278)  with  the 
same  upright,  which  is  set  upon  the 
ring  at  a  point  slightly  in  advance  of 
its  fellow.  The  objects  of  the  shape 
of  the  ring  and  of  its  inclination  are 
these :  its  anterior  part  is  but  slightly 
curved  to  conform  to  the  surface  of 
the  groin;  its  posterior  segment  is 
expanded  to  accommodate  the  thick- 
ness of  the  buttock;  the  anteropos- 
terior inclination  allows  the  ring  to 
rest  comfortably  beneath  the  tuber- 
osity of  the  ischium.  The  lateral  in- 
clination which  follows  the  line  of 
Poupart's  ligament  is  made  neces- 
sary by  the  greater  length  of  the 
outer  bar,  which  in  order  to  assure 
better  support  and  less  pressure,  rises 
above  the  level  of  the  trochanter 
major. 

The  ring  is  made  somewhat  larger 
than  the  thigh  to  allow  for  padding 
with  felt.  This  should  be  thicker  on 
the  inner  and  posterior  surface,  w^here 
the  weight  is  borne,  than  on  the  ante- 
rior and  outer  part.  The  padded  ring  is  then  smoothly  covered 
with  basil  leather.  As  used  at  the  Hospital  for  Ruptured  and 
Crippled,  the  brace  is  made  from  two  to  three  inches  longer  than 
the  leg,  to  serve  as  a  stilt  like  the  hip  splint.  To  the  foot-piece 
two  straps  are  attached  on  either  side  to  provide  for  traction  on 
the  limb  and  to  hold  the  brace  securely  in  its  place.  A  band  of 
leather  is  drawn  between  the  bars  at  the  upper  third  and  another 
at  the  lower  third  of  the  brace  to  serve  as  supports  for  the  thigh 
and  calf.     Adhesive  plasters,  reaching  from  the  knee  to  the  ankle. 


The  Bradford-Goldthwait  genuclast 
for  the  correction  of  flexion  deformity 
and  subluxation  at  the  knee.  Counter- 
pressure  is  applied  over  the  lower  ex- 
tremity of  the  femur.  Subluxation  is 
prevented  during  the  forcible  correc- 
tion by  means  of  the  screw  and  strap 
beneath  the  head  of  the  tibia,  by  which 
it  is  drawn  forward. 


422 


ORTHOPEDIC  SURGERY 


pro^-ided  with  buckles  above  the  malleoH,  having  been  apphed, 
the  ring  is  pushed  firmly  against  the  perineum  and  is  held  in  posi- 
tion by  buckling  the  straps  to  the  traction  plasters  with  as  much 
tension  as  the  comfort  of  the  patient  will  permit.  The  thigh  and 
leg  supports  should  fit  the  parts  perfectly;  the  knee  is  then  fixed 
in  its  place  by  a  bandage  drawn  tightly  about  it  and  the  lateral 
bars.     Ankle  and  heel  straps  complete  the  adjustment  (Fig.  281). 


Fig.  277 


Fig.   27S 


The  Thomas  knee-splint,   showing  the 
inner   bar    B    placed  farther  to  the  front 
than   the  outer  bar  C;  A  is  the  lowest 
part  of  the  ring;  upon  this  rests  the  tuber- 
osity of  the  ischium. 


The  ring  of  the  Thomas  knee-splint  after 
padding.    (Ridlon.) 


In  cases  in  which  the  joint  is  sensitive  and  in  which  there  is 
a  tendency  to  deformity  the  entire  limb  is  in  addition  enclosed  in 
a  light  plaster  bandage,  so-called  "skin  fitting,"  applied  directly 
upon  a  flannel  bandage. 

If  the  brace  is  attached  by  means  of  the  adhesive  plaster  straps, 
a  certain  amount  of  traction  is  assured,  together  with  additional 
accuracy  of  adjustment;  and  Ijy  the  traction  and  by  the  direct 
pressure  on  the  knee  the  slighter  degrees  of  deformity  may  be 
reduced  without  discomfort.  In  acute  cases  preliminary  rest  in 
bed  is  advisabh;,  and  crutches  may  be  employed  in  the  early  stages 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        423 

of  ambulatory  treatment.  But  during  the  greater  part  of  the 
disease  the  spUiit  serves  as  a  perineal  crutch  and  l>y  the  use  of 
slight  corrective  force  when  the  plaster  bandages  are  applied,  or 
by  traction  at  times  toward  one  or  the  other  upright,  lateral  dis- 
tortion of  the  limb  may  be  corrected  during  the  course  of  treat- 
ment. This  brace  may  be  used  in  the  treatment  of  very  young 
children  if  it  is  carefully  fitted  and  if  the  parts  are  kept  clean  and 
dry,  and  it  is  an  effective  brace  for  all  ages,  and  for  all  conditions 
of  disease. 


Fig.   279 


Fig.  280 


Showing  the  front  of  the  ring  of  the 
Thomas  knee-splint. 


Showing  the  back  of  the  ring  of  the 
Thomas  knee-splint.     (Ridlon.) 


The  Caliper  Brace. — The  traction  may  be  discarded  and  the 
brace  may  be  held  in  position  by  a  shoulder  band,  or  it  may  be 
used  as  a  so-called  caliper  splint.  In  this  form  it  was  almost 
exclusively  employed  by  Mr.  Thomas  in  his  later  practice  and  at 
the  present  time  by  Ridlon,^  the  long  brace  l)eing  used  sim])ly  for 
a  bed  splint.  As  a  caliper  brace  the  two  bars  are  cut  otf,  turned 
directly  inward  at  a  I'ight  angle,  and  are  inserted  into  a  steel 
tube,  which  is  passed  through  the  heel  of  the  shoe.  The  bars  are 
made  slightly  longer  than  the  limb,  so  that  the  patient's  heel  is 
lifted  nearly  an  inch  from  the  inside  of  the  shoe  when  walking; 
thus,  the  jar  of  impact  with  the  ground  is  prevented.     The  brace 


'  Transactions  American  Orthopedic  Association,  vol.  vi. 


424 


ORTHOPEDIC  SURGERY 


Fig.   281 


is  fixed  in  position  by  a  leather  band  beneath  the  knee  and  another 
beneath  the  calf,  and  the  limb  is  held  extended  by  pressure  pads 
applied  to  the  thigh  and  leg,  as  illustrated  (Fig.  282),  Ridlon 
uses  the  brace  to  reduce  deformity  by  direct  pressure  backward  on 
the  knee  by  means  of  bandages,  opiates  being  given  to  relieve  pain. 
Other  braces  may  be  employed,  for  example,  the  traction  hip 

splint,  but  as  the  Thomas  brace 
answers  every  requirement,  it  seems 
unnecessary  to  describe  others  in  this 
connection. 

Accessory  Treatment. — The  acces- 
sories to  protective  treatment,  which, 
of  course,  includes  the  proper  atten- 
tion to  the  general  condition  of  the 
patient,  are  local  applications,  injec- 
tions, and  venous  stasis.  They  are 
classed  as  accessories  because  none  of 
them  is  essential  to  successful  treat- 
ment. 

The  local  application  of  cautery,  ap- 
plied at  intervals  of  a  week,  or  less, 
may  add  to  the  comfort  of  the  patient 
and  stimulate  the  reparative  pro- 
cesses. The  a;-ray  appears  to  act  in 
a  somewhat  similar  manner ;  it  re- 
lieves pain,  and  in  most  instances  the 
infiltration  of  the  tissues  becomes  less 
marked. 

Ichthyol  ointment  of  a  strength  of 
about  40  per  cent,  certainly  relieves 
pain  and  local  congestion  in  certain 
instances.  Firm  compression  by  means 
of  a  flannel  bandage  and  by  the  ad- 
hesive plaster  strapping  is  of  value, 
especially  in  the  infiltrating,  "boggy" 
type  of  disease.  The  knee  is  the  joint  into  which  injections  of 
iodoform  emulsion  may  be  made  most  easily.  Such  injections  are 
more  likely  to  be  of  service  in  the  synovial  than  in  the  osteal  type 
of  disease.  About  10  c.c.  of  a  10  per  cent,  emulsion  of  iodoform 
in  sweet  oil  may  be  injected  through  a  trocar  into  the  distended 
capsule  at  intervals  of  several  weeks.  It  is  then  distributed  by 
gentle  massage.     It  may  aid  tlie  reparative  processes  by  an  irrita- 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT       425 


Fig.   282 


tive  stimulation,  but  it  apparently  exerts  no  very  direct  influence 
on  the  tuberculous  process. 

Bier's  treatment  by  passive  congestion  may  be  easily  applied 
to  the  joint.  The  limb  up  to  the  joint  is  firmly  bandaged  by 
a  flannel  bandage.  A  rubber  band  is  then 
applied  immediately  above  the  joint  with 
sufficient  tension  to  retard  the  return  of  the 
venous  blood.  The  joint  then  becomes 
swollen  and  congested.  The  congestion  is 
applied  for  an  hour  or  more  at  a  time, 
once  or  twice  daily.  Passive  congestion  ap- 
parently increases  the  stability  of  the  granu- 
lation tissue  and  its  further  transformation 
to  fibrous  tissue.  The  method  should  not  be 
employed  during  the  acute  phases  of  the 
disease.    (See  page  262.) 

Treatment  during  Convalescence. — During 
the  active  stage  of  the  disease  the  brace  must 
be  worn  day  and  night.  During  the  stage  of 
recovery  it  may  be  removed  at  night  to  allow 
for  motion  at  the  knee,  and  later  a  form  of 
walking  brace  (Fig.  193)  that  will  allow  a 
limited  motion  at  the  knee  may  be  of  service  ; 
but  this  is  not  an  essential  in  treatment.  If 
slight  knock-knee  remains  after  recovery,  it 
may  be  overcome  by  the  use  of  a  Thomas 
knock-knee  brace,  which  will  also  serve  as  a 
protection  to  the  weak  joint.  The  indica- 
tions of  cure  have  been  discussed  under  hip 
disease.  In  brief,  when  sufficient  time  has 
elapsed  to  permit  of  natural  cure  ;  when  there 
have  been  no  symptoms  of  active  disease  for 
months ;  when  muscular  spasm  has  disap- 
peared, one  may  tentatively  remove  the  brace 
in  the  manner  described.  But  any  symptom 
of  disease,  and  particularly  increasing  limita- 
tion of  the  range  of  motion,  or  a  tendency 
toward  deformity,  indicates  the  necessity  for 
continued  protection.  If  anchylosis  is  pres- 
ent, supervision  and  occasional  treatment  will 
be  required  during  the  period  of  growth  in 
order  to  prevent  deformity. 


The  caliper  splint.  E, 
the  ring  around  the  upper 
part  of  the  thigh.  A,  pad 
for  backward  pressure.  B, 
bandage.  C,  bandage.  F, 
leather  sling  for  support  at 
the  back  of  the  limb.  D.  a 
strip  of  bandage  fastening 
together  the  pressure  pads 
to  prevent  slipping  and 
consequent  loss  of  pressure. 
(Ridlon  and  Jones.) 


426  ORTHOPEDIC  SURGERY 

Extra-articulax  Disease  and  Operative  Intervention. — In  certain 
cases,  especially  in  young  children,  the  disease  about  the  epi- 
physeal cartilage  of  the  femur  or  of  the  tibia  may  find  its  way  to 
the  exterior  of  the  bone  before  it  invades  the  joint.  This  fortu- 
nate course  is  indicated  by  local  sensitiveness  and  swelling  over 
one  of  the  condyles  of  the  femur  or  about  the  head  of  the  tibia. 
In  such  instances  the  thorough  removal  of  the  disease  is  indi- 
cated, or  if  a  Roentgen  picture  shows  that  the  disease  is  accessible 
even  though  it  is  not  immediately  below  the  surface,  an  explora- 
tory operation  may  be  advisable.  An  incision  is  made,  usually 
over  the  internal  condyle  of  the  femur.  The  periosteum  is  raised 
and  a  portion  of  the  cortex  is  removed  in  order  to  expose  the 
spongy  bone  on  either  side  of  the  epiphyseal  cartilage. 

In  many  instances  an  area  of  softening  will  be  found.  This 
must  be  thoroughly  removed.  The  cavity  may  be  treated  with 
pure  carbolic  acid  or  the  cautery,  or  filled  with  iodoform  mass 
and  the  wound  is  then  closed.  In  favorable  cases  prompt  opera- 
tive intervention  may  cut  short  the  course  of  the  disease. 

Abscess. — Abscess  is  present  as  a  complication  in  about  one- 
third  of  the  cases  that  have  received  efficient  protection,  and  in  a 
larger  percentage  of  those  in  which  treatment  has  been  neglected. 

It  was  present  in  51  per  cent,  of  Koenig's  cases^  and  in  47  per 
cent,  of  three  hundred  final  results  reported  by  Gibney.^  At  the 
knee,  as  at  other  joints,  the  infected  abscess  is  the  most  dangerous 
complication  of  the  disease,  as  is  illustrated  by  Koenig's  statistics : 

Death-rate  in  cases  without  abscess 25  per  cent. 

"  "  with  abscess 46 

Although  in  many  instances  abscess  indicates  an  extensive  and 
destructive  disease  of  the  bone,  yet  the  exhausting  suppuration 
that  is  an  indirect  cause  of  death  is  suppuration  from  infected 
areas  in  the  thigh  and  leg,  which  may  have  little  direct  relation 
to  the  extent  of  the  original  disease.  It  should  be  the  aim  in 
treatment  to  prevent  this  burrowing  of  fluid  after  the  capsule  has 
been  perforated,  and  to  prevent  overdistention  of  the  capsule  even, 
in  order  to  lessen  the  macerating  effect  of  the  tuberculous  fluid 
upon  the  cartilages.  When  the  fluid  within  the  joint  is  of  con- 
siderable amount,  and  when  it  is  increasing  in  quantity,  it  may 
be  removed  by  aspiration,  (jr  a  better  procedure  is  to  incise  the 
capsule.  This  will  p(!rmit  thorough  removal  of  its  fluid  and 
solid  contents,  after  which  the  opening  may  be  closed  with  sutures. 

'  Loc.  cit.  -  Americmi  ./ournal  of  tin;  Medical  Sciences,  Oclober,  1893. 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        427 

Tuberculous  abscess  which  has  perforated  the  capsule  may  be 
treated  in  the  same  manner,  or  it  may  be  drained  subsequently, 
according  to  the  indications.  Unless  the  abscess  is  infected 
careful  bandaging  of  the  thigh  and  leg  should  prevent  burrowing. 

Synovial  Tuberculosis. — In  the  forms  of  synovial  tuberculosis 
that  resemble  chronic  synovitis  the  fluid,  if  the  quantity  is  large, 
may  be  evacuated  by  an  incision  in  the  capsule  which  will  allow 
for  exploration  and  for  removal  of  the  fibrinous  masses  that  are 
often  present.  Afterward  the  interior  of  the  joint  may  be  treated 
with  an  application  of  a  strong  solution  of  chloride  of  zinc  or  pure 
carbolic  acid.  This  sets  up  an  active  reaction  which  causes  adhe- 
sions within  the  capsule,  and  exerts  a  favorable  influence  on  the 
course  of  the  disease.  A  protective  brace  should  be  worn  to 
guard  the  joint  from  sudden  twists  and  strains  and  to  limit  the 
range  of  motion  within  the  painless  arc  (Fig.  193).  The  adhesive 
plaster  strapping  may  be  employed  in  cases  of  this  class  with  great 
advantage.  It  is  in  this  type  of  disease  that  passive  conges! ion  is 
most  effective.  The  same  is  tme  of  the  injection  of  iodoform 
emulsion.  Theoretically,  its  use  should  modify  the  infectious 
quality  of  the  tuberculous  fluid  and  lessen  the  danger  of  infection 
with  pyogenic  germs,  and  on  this  ground,  rather  than  because  it 
actually  shortens  the  course  of  the  disease,  it  may  be  recom- 
mended. 

Arthrectomy. — -When,  as  in  exceptional  cases,  the  disease  is  pro- 
gressive and  shows  no  tendency  toward  recovery,  and  particu- 
larly if  an  infected  abscess  communicating  with  the  joint  makes 
efficient  drainage  difficult,  the  operation  of  arthrectomy  may  be 
indicated. 

An  Esmarch  bandage  having  been  applied,  the  joint  is  thor- 
oughly exposed  by  a  curved  anterior  incision  passing  above  or 
below  or  through  the  patella,  and  all  the  diseased  tissue  is  re- 
moved; that  in  the  soft  parts  is  cut  away,  and  foci  in  the  bone 
are  excavated  with  the  chisel  and  scoop.  If  infection  be  present 
the  joint  may  be  packed  with  gauze,  the  leg  being  fixed  in  the 
position  of  flexion;  but  in  other  instances  the  w^oinid  is  closed 
with  or  without  drainage  as  may  seem  atlvisable.  In  a  large 
proportion  of  cases  primary  healing  may  be  obtained.  By  the  pro- 
cedure one  may  hope  to  cure  the  disease,  but  in  all  but  exceptional 
cases  the  functional  result  will  be  anchylosis.  The  operation  has 
the  advantage  over  complete  excision  in  that  less  bone  is  removed, 
and  that  the  epiphyses,  in  part,  at  least,  remain;  thus,  the  imme- 
diate as  well  as  the  ultimate  shortening;  is  less  than  after  excision. 


428  ORTHOPEDIC  SURGERY 

Results  of  Arthrectomy. — The  direct  death-rate  of  the 
operation  is  small.  In  150  cases  reported  by  Koenig  but  3  deaths 
were  attributable  to  the  operation  itself.  The  final  results  in  114 
of  these  cases,  in  which  the  operation  was  performed  in  childhood, 
were  as  follows: 

Patients  cured  and  living 90 

Cured  of  the  local  disease,  but  not  living  at  the  time 

of  the  investigation 10 

Practically  cured,  insignifieant  fistuhe  remaining      .  2 

102  =  89.5  per  ct. 

Li\Tng,  not  cured 5 

Deaths  before  the  cure  of  the  local  disease    ...  7 

12  =  10.5  per  ct. 

Thus  in  89  per  cent,  of  the  cases  the  operation  was  successful 
as  far  as  the  cure  of  the  local  disease  was  concerned.  In  75  per 
cent,  of  the  successful  cases  immediate  cure  was  attained;  in  25 
per  cent,  fistulse  persisted  for  a  longer  or  shorter  time.  In  10 
cases  some  motion  was  retained,  but  in  the  others  anchylosis  fol- 
lowed the  operation.  In  about  70  per  cent,  of  the  cases  the  limb 
was  practically  straight;  in  30  per  cent,  it  was  distorted.  This 
shows  the  necessity  of  continued  supervision  and  in  many  in- 
stances of  protective  treatment  during  the  growing  period  in  all 
cases  in  which  anchylosis  is  present  from  whatever  cause. 

In  forty-eight  cases  in  which  the  operation  had  been  performed 
before  the  tenth  year,  and  in  which  the  limbs  were  straight,  the 
influence  of  the  operation  on  the  growth  was  investigated. 

Years  elapsed  Average  shortening 

Number  of  cases.                                            since  operation.  in  cm. 

6 2  1 

5 3  1.6 

4 4  1 

3 5  2 

19 6-7  2 

11 8-13  2.5 

These  measurements  indicate  that  the  shortening  is  not  likely  to 
be  very  great  as  a  result  of  the  operation,  certainly  very  much  less 
than  after  complete  or  even  partial  excision  performed  at  the 
same  age. 

Excision. — Excision  of  the  joint  in  childhood  has  been  practi- 
cally abandoned,  because  of  the  great  sliortening  that  follows 
complete  removal  of  the  epiphyses,  and  because  so-called  partial 
excision — that  is,  the  removal  of  the  thin  sections  of  bone  from  the 
surfaces  of  tlie  femur  and  tibia,  leaving  the  cartilages — is  usually 
an  unnecessary  operation,  in  the  sense  tliat  disease  that  might 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        429 


be  cured  by  this  procedure  might  have  been  cured  by  conservative 
methods. 

Early  excision  in  adult  cases  is  often  indicated  because  it  will 
assure  a  cure  of  the  disease  in  a  short  time,  whereas  mechanical 
treatment  will  at  best  require  years  of  disability  with  no  certain 
prospect  of  absolute  cure  at  the  end  of  the  period.  If,  therefore, 
the  disease  has  progressed  sufficiently  to  indicate  that  the  natural 
cure  would  result  in  anchylosis,  or  if  the  time  required  for  natural 
cure  is  of    importance    to    the 


Fig.  283 


patient,  early  excision  may  be 
advised  in  the  case  of  the  adult 
or  adolescent  whose  growth  is 
nearly  completed. 

The  operation  is  performed 
under  the  Esmarch  bandage, 
and  the  joint  is  exposed  by  the 
anterior  incision,  as  in  the  oper- 
ation of  arthrectomy.  All  the 
diseased  tissues  are  cut  away 
and  sections  of  the  bones,  par- 
allel to  the  articular  surfaces, 
are  removed  sufficient  in  depth 
to  include  all  the  diseased  area. 
The  sections  should  allow  the 
bones  to  be  brought  into  close 
apposition  and  they  should  be 
held  by  strong  sutures  of  catgut. 
The  vessels  having  been  ligated, 
the  wound  may  be  closed  with 
or  without  drainage,  as  may  be 
indicated  by  the  character  of  the 
disease,  a  plaster-of-Paris  dress- 
ing is  applied,  and  the  limb  is 
elevated.  Mechanical  support  is  of  service  in  the  after-treatment 
in  lessening  the  discomfort  and  hastening  the  cure. 

Results  of  Excision. — In  Koenig's  statistics  of  300  excisions, 
6  deaths  were  due  directly  to  the  operation,  and  23  others  occurred 
during  the  course  of  the  after-treatment — a  total  of  29  (9.G  per 
cent.). 

In  23  instances  amputation  was  afterward  performed  because 
of  failure  of  the  operation.  The  good  results  are  classed  by 
Koenig  as  75  per  cent.,  the  bad  as  25  per  cent.     In  193  cases 


Deformity  and  shortening  resulting  from  ex- 
cision of  the  knee  in  childhood. 


430  ORTHOPEDIC  SURGERY 

the  position  of  the  limb  in  after  years  was  investigated.  It  was 
straight  in  175,  distorted  in  IS,  all  bnt  1  of  this  latter  group  being 
in  children.  Of  400  resections  of  the  knee  in  Bruns'  clinic  final 
results  were  ascertained  in  379  cases.  The  early  results  were  as 
follows: 

Discharged,  well 343 

with  fistulas 29 

Amputated 17 

Dead 17 

Not  cured 4 

Final  results: 

Well 280  1 

With  fistulas 3   [   Q^^^  j.g^^jjg  g7  9  pg^  ^^^^ 

Dead,  but  cured  of  local  disease   .      .  4,5   I 

Dead,  not  cured 3  J 

Living,  not  cured l*^  1 

^®^'^'        '.'   .    "  6   I  Bad  results 'l2  percent. 

Died  in  clinic 7    [ 

Amputated 23  j 

Curvature  of  the  limb: 

Straight 27.1  per  cent. 

Moderately  flexed 28.0 

Mechanically  fle.xed 44.9  " 

Amputation. — This  operation  is  indicated  as  a  life-saving  meas- 
ure. When  the  disease  is  so  extensive  as  to  require  complete 
removal  of  the  epiphyses  in  early  childhood,  amputation  is 
the  preferable  op;iration,  as  the  limb,  aside  from  requiring  con- 
stant protection  to  prevent  deformity,  will  be  so  short  as  to  be  of 
little  practical  use. 

Operations  for  the  Relief  of  Final  Deformity. — In  the  majority 
of  the  cases  deformity  can  be  rectified  by  one  of  the  methods 
already  described.  If,  however,  there  is  bony  anchylosis  in  an 
attitude  of  marked  flexion  the  limb  ma}'  be  straightened  by  the 
removal  of  a  sufficient  wedge  of  bone  from  the  joint.  The  defor- 
mity may  be  remedied  almost  equally  well  by  linear  osteotomy 
of  the  femur  just  above  the  joint,  supplemented  if  the  deformity 
is  extreme  by  a  secondary  osteotomy  of  the  tibia.  If  flexion 
deformity  is  of  long  standing  the  correction  should  not  be  com- 
pleted at  the  first  operation  out  preferably  at  several  sittings  to 
permit  the  adaptation  of  the  soft  parts  and  the  bloodvessels  to  the 
new  attitude.  Simple  osteotomy  is  to  be  preferred  in  young  sub- 
jects, as  no  bone  is  removed. 

Genu  valgum  may  be  corrected  by  a  similar  operation.  (See 
Osteotomy  for  Knock-knee.) 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        431 

In  certain  selected  cases  the  joint  may  he  opened  fc^r  the  pur- 
pose of  separating  the  bones  and  interposing  flaps  of  flbro- 
muscular  tissue.  Although  the  prospect  of  restoring  useful  motion 
is  slight,  it  will  at  least  serve  to  correct  deformity.     See  Anchylosis. 

Prognosis. — The  most  important  statistical  evidence  on  the 
course  and  the  outcome  of  tuberculous  disease  of  the  knee-joint 
in  childhood  has  been  presented  by  Gibney.  The  statistics  com- 
pleted in  1S92  were  the  result  of  an  investigation  of  499  cases 
treated  during  a  period  of  twenty  years,  1868-1887.  In  but 
300  of  these  could  definite  information  be  obtained.^ 

Eighty-seven  per  cent,  of  the  cases  were  in  children,  and  51 
per  cent,  of  the  patients  were  less  than  five  years  of  age  at  the 
inception  of  the  disease. 

The  cases  were  divided  into  three  classes,  according  to  the 
treatment  that  had  been  followed: 

1.  The  expectant  treatment.  In  this  class  no  apparatus  Avas 
employed,  or,  if  employed,  it  had  been  efficient. 

2.  The  fixation  treatment.  In  this  class  the  joint  haJ  been  more 
or  less  efficiently  splinted,  but  not  protected  from  impact  with 
the  ground. 

3.  The  protective  treatment.  In  this  class  the  joint  had  been 
splinted  and  protected  from  jar,  and  the  mechanical  treatment 
had  been  efficient. 

The  results  were  classified  as  follows: 


Total. 

Excisions. 

Anipuiations. 

Deaths. 

Under 
treatment. 

Cured. 

Expectant  . 
Fixation      . 
Protection . 

71 
190 
39 

5 
9 
0 

3 
1 
0 

3.T 

2 

9 
31 
11 

lU 
26 

300 

14 

4 

40 

51 

191 

Mortality. — The  total  deaths  in  the  300  cases  wimv  4( 
per  cent.);  2G  of  these  were  from  causes  diirctly  or  im 
connected  with  the  disease  (8.()  per  cent.),  viz.: 

Operative  shock 1 

Prolonged  suppuration \f> 

Tuberculous  meningitis 6 

Phthisis 3 

26 
Intercurrent  diseases 14 

40 

'  -American  Journal  of  the  Medical  Sciences.  October,   1S93. 


I   (13.3 

lirectlv 


432 


OB THOPEDIC  SURGEB Y 


Function. — The  functional  results  as  regards  motion  in  the 
cases  in  which  conservative  treatment  had  been  continued  to  the 
end,  including  the  cases  still  under  observation,  242  of  300,  were 
as  follows: 


Total. 

Motion  retained. 

Anchylosed. 

Expectant 

Fixation 

Protection 

60 
145 
37 

44  or  73  per  cent. 
113  "77       " 
34  "  95       " 

16 

32 

3 

242 

191  or  79  per  cent. 

51 

Of  the  191  patients  who  retained  a  movable  joint,  74  had 
had  abscesses,  3  or  more  cicatrices  being  present  in  39. 

As  to  the  range  of  motion,  in  74  it  was  from  45  degrees  to  normal 
and  in  41  more  than  90  degrees;  thus  30  per  cent,  of  the  patients 
retainefl  a  fair  range  of  motion. 

Deformity. — In  51  cases  anchylosis  was  present;  in  16  of  these 
the  limb  was  practically  straight,  in  35  it  was  flexed  more  than 
30  degrees  (69  per  cent.). 

These  statistics  again  illustrate  the  great  tendency  toward 
deformity,  when  during  the  growing  period  there  is  anchylosis  at 
the  knee  from  whatever  cause. 

In  the  191  cases  in  which  motion  was  retained  the  limb  was 
practically  straight  in  125  (65  per  cent.).  In  49  others  the  flexion 
was  less  than  25  degrees,  and  in  but  16  could  the  deformity  be 
classed  as  bad  (8  per  cent.). 

In  10  cases  only  did  relapse  occur  after  apparent  cure. 

In  but  16  of  the  449  cases  was  there  involvement  of  other  joints 
while  the  patients  were  under  observation  (3.2  per  cent.).  lu 
8  of  these  the  spine  was  involved,  in  2  the  hip,  and  in  6,  other 
joints. 

The  influence  of  age  upon  the  death-rate  and  the  ultimate 
causes  of  death  are  illustrated  by  Koenig's  statistics,  the  death- 
rate  being  much  higher,  at  least  in  the  cases  in  early  childhood, 
than  in  this  country. 

According  to  Koenig's  statistics,  the  death-rate,  direct  and 
indirect,  from  disease  of  the  knee-joint,  was  as  follows: 


323  children  (1  to  15  years  of  age),      deaths 
226  patients  (16   "  30     "  "    ), 

fig        "         (31   "  40     "  "     ), 

74        "         more  than  40  yearH  of  age     " 


65  ='20  per  cent. 
.  61  =  24      " 
30  =  44      " 
45  =  60      " 


TUBERCULOUS  DISEASE  OF  THE  KNEE-JOINT        433 
Causes  of  Death. 

Deaths    from  causes  not  connected  with  the  disease  .      .    14  =  2.0  per  cent. 

"     following  operations 18  =  2.5       " 

"     caused  by  tuberculosis,  141  =  22.5  per  cent,  of  all  cases  and  80 
per  cent,  of  all  the  deaths. 

Tuberculosis  of  the  knee 1 

"           "         lungs 94 

General  tuberculosis 30 

Tuberculous  meningitis 7 

Acute  miliary  tuberculosis 3 

Tuberculosis  of  other  parts 6 

141 

It  may  be  noted  that  16  of  the  40  deaths  in  Gibney's  cases 
were  due  to  prolonged  suppuration,  and  that  of  51  cases  still 
under  observation  26  had  been  treated  for  ten  years  or  longer, 
and  were  still  uncured.  This  indicates  that  in  a  larger  propor- 
tion of  the  cases  conservative  methods  should  have  been  supple- 
mented by  more  radical  treatment.  Still,  taken  as  a  whole,  the 
results,  although  the  mechanical  treatment  was,  in  many  instances, 
far  from  efficient,  are  much  better  than  any  others  that  have  been 
presented. 

General  Conclusions. — On  this  evidence  the  following  con- 
clusions seem  to  be  justified:  The  death-rate  in  childhood  from 
all  causes  should  be  less  than  10  per  cent.  The  duration  of 
treatment  is  from  two  to  five  years.  Recovery  T\ath  a  useful 
range  of  motion,  when  the  diagnosis  has  been  made  at  an  early 
stage  and  when  efficient  mechanical  treatment  has  been  employed, 
may  be  predicted  in  50  per  cent,  of  the  cases. 

Deformity  can  always  be  prevented  by  treatment  and  by  super- 
vision. Under  favorable  conditions  radical  operations  are  not 
often  indicated,  but  when  indicated  they  should  not  be  delayed 
too  long.  Amputation  of  the  limb  should  prevent  death  from 
prolonged  suppuration.  In  a  certain  proportion  of  cases  the 
disease  may  be  cut  short  by  early  exploratory  operations  for  the 
removal  of  foci  of  disease  in  the  bone  before  the  joint  has  become 
involved. 

Although  the  benefits  of  protective  treatment  are  as  cA'ident  in 
disease  of  the  adult  as  in  childhood,  yet  early  operation  is  often 
indicated  in  this  class,  because  of  the  necessity  for  shortening  the 
period  of  disability,  and  because  excision  assures  a  straight  and 
useful  limb. 


28 


CHAPTER   X. 

N OX-TUBERCULOUS   AFFECTIONS   AND   DEFORMITIES   OF   THE 

KNEE-JOINT. 

Strains  and  Injuries  of  the  Knee   in  Childhood. 

Injury  of  the  knee  in  childliood  may  cause  local  discomfort 
and  persistent  flexion  of  the  leg,  even  when  but  little  synovial 
effusion  is  present.  In  this  class  of  cases  the  application  of  a 
plaster  bandage,  under  sufficient  traction  to  overcome  the  deform- 
ity, is  of  service  in  placing  the  part  at  rest  and  preventing  further 
injury.  The  importance  of  treating  promptly  slight  injuries  of 
the  joints  in  childhood,  especially  in  the  class  of  patients  predis- 
posed to  tuberculous  infection,  has  been  mentioned  already  in  the 
consideration  of  hip  disease. 

Muscular  "cramp,"  a  form  of  tetanic  contraction,  induced 
possibly  by  injury,  which  fixes  the  limb  in  a  flexed  or  extended 
position,  is  sometimes  seen  in  children  of  a  susceptible  or  nervous 
temperament.     The  treatment  is  similar  to  that  of  strains. 

Acute  Synovitis. 

The  knee  from  its  size  and  position  is  especially  liable  to  injury, 
which  if  of  any  severity  is  usually  followed  by  effusion  of  fluid 
within  the  joint  (synovitis).  Its  symptoms  are  discomfort,  swelling, 
local  heat,  and  limitation  of  motion.  According  to  Tenney^  the 
patella  floats  when  30  c.c.  of  fluid  is  contained  in  the  joint,  the 
extreme  of  normal  capacity  being  200  c.c. 

Injury  and  its  attendant  synovitis  may  be  treated,  immedi- 
ately, by  splints,  by  elevation  of  the  limb,  by  the  application  of 
ice-bags  and  th(i  like;  but  after  the  acute  symptoms  have  sub- 
sided the  absorption  of  the  effused  fluid  is  aided  by  functional 
use  of  the  limb,  if  the  joint  is  properly  protected.  One  of  the 
most  efficient  methods  of  treatment  is  that  by  means  of  the  ad- 
hesive plaster  strapping  advocated  by  Cottrell  and  Gibney.  The 
entire  surface  of  the  knee,  except  a  narrow  space  in  the  popliteal 

'   Aiirial.H  of  Surgery,  July,  1904. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT    435 

region,   is   firmly  strapped  with  overlapping  layers  of  adhesive 

plaster,  extending  from  the  upper  third  of  the  leg  to  the  middle 

third  of  the  thigh;  and  over  this  a  flannel  bandage  is  applied; 

or  if  the  leg  is  swollen,  the  entire  limb  should  be  firmly  bandaged 

with  elastic  stockinette  bandage,  from  the  toes  to  the  upper  third 

of  the  thigh  in  addition  (Fig.  291).     The  adhesive  plaster  serves 

as  a  support  which  allows  a  certain  degree  of  motion,  sufficient  to 

stimulate  the  circulation,  and  thus  to  hasten  the  restoration  of 

the   normal   condition.     If  greater   compression   is   desired,   the 

entire  joint  may  be  covered  with  the  adhesive  plaster  as  suggested 

by  Hoffmann.^     A  pad  of  cotton  is  placed  in  the  popliteal  space, 

a  close-fitting  stocking  leg  is  drawn  over  the  knee,  and  about 

this  circular  bands  of  plaster  are  drawn  as  tightly  as  the  comfort 

of  the  patient  will  permit.     The  adhesive  plaster  strapping  is 

renewed  from  time  to  time,  as  the  swelling  diminishes,  and  its 

use  is  continued  until  the  symptoms  have  entirely  disappeared. 

Chronic  traumatic  synovitis  may  be  treated  in  a  similar  manner, 

although  if  the  effusion  is  persistent  the  fluid  may  be  removed 

by  aspiration.     If  the  ligaments  are  lax,  a  supporting  brace  may 

be  required  for  a  time  (Fig.  193).     Massagqj  and  exercises  and 

static  electricity  are  of  service  in  the  stage  of  recovery  to  restore 

the  strength  and  activity  of  the  supporting  muscles. 

Chronic  and  Recurrent  Synovitis. 

Chronic  synovitis  is  of  far  greater  interest  from  the  orthopedic 
standpoint  than  the  acute  form  because  it  is  usually  sjTnptomatic 
of  some  general  pathological  condition  or  change  within  the  joint. 

Bennet^  has  analyzed  750  cases,  the  apparent  causes  of  the 
effusion  being  as  follows : 

Local. 

1.  Internal  derangement  of  the  joint' 428 

2.  Loose  bodies  in  the  joint 24 

3.  Genu  valgum 4 

General. 

1.  Osteoarthritis 107 

2.  Rheumatism  and  gout 30 

3    Syphilis 42 

4.  GonorrhcEa 28 

5.  Malaria IS 

C.  Hffimophilia 3 

'  New  York  Medical  Journal,  January  27,  1900. 
-  Lancet,  January  7,  1905. 


436  OB THOPEDIC  SURGERY 

In  56  cases  no  cause  could  be  assigned  and  13  were  instances 
of  what  he  calls  "quiet  effusion." 

Internal  Derangement  of  the  Knee-joint.     (Hey.) 

Internal  derangement  signifies  sudden  interference  with  the 
function  of  the  joint  which  may  be  due  to  (a)  loose  bodies  in  the 
joint;  (h)  displacement  or  fracture  of  a  semilunar  cartilage;  (c) 
other  injury. 

Loose  Bodies  in  the  Knee-Joint.^ — Loose  bodies  in  the  knee- 
joint  may  be  composed  of  portions  of  fibrin,  fragments  of  synovial 
membrane,  or  bits  of  cartilage  or  bone,  and  the  like.  In  certain 
forms  of  synovial  tuberculosis  and  osteoarthritis  these  loose  bodies 
may  be  present  in  large  numbers.  From  the  therapeutic  stand- 
pomt,  however,  the  important  cases  are  those  in  which  the  joint  is 
otherwise  normal.  In  this  class  the  foreign  body  is  sometimes 
detected  by  the  patient  as  a  smooth,  movable  object  on  one  or  the 
other  side  of  the  patella;  but  in  many  instances  the  first  sign  of 
its  presence  is  interference  with  the  function  of  the  joint.  After 
a  sudden  movememt  or  when  the  knee  has  been  flexed,  as  in  the 
kneeling  position,  or  without  appreciable  cause,  severe  pain  in 
the  knee  is  felt  and  the  joint  may  be  fixed  in  the  position  of  flexion. 
By  massage,  manipulation,  or  spontaneously  the  foreign  body 
is  dislodged  from  between  the  surfaces  of  the  bone  and  movement 
becomes  free  and  painless,  but  discomfort  remains  for  a  time 
and  in  most  instances  synovial  effusion  follows.  These  symp- 
toms recur  at  intervals,  and  the  disappearance  of  the  movable 
body  from  its  accustomed  place  at  such  times  may  demonstrate 
its  relation  to  the  disability. 

Displacement  of  a  Semilunar  Cartilage.— Displacement  of  a  , 
semilunar  cartilage  is  usually  of  traumatic  origin.  The  tinnreal  'jt&i;'^' 
cartilage  is  most  often  affected.  The  displacement  is  usually 
caused  by  an  outward  twist  of  the  tibia  upon  the  femur.  The 
patient's  limb  is  fixed  in  the  attitude  of  flexion,  and  in  certain 
instances  an  irregularity  may  be  detected  at  the  inner  and  upper 
border  of  the  tibia. 

T(j  replace  the  cartilage  the  leg  should  be  flexed,  then  suddenly 
extended  and  rotated  inward.  In  some  instances  an  anaesthetic 
may  be  required.     The  displacement  is  followed  by  discomfort 

'  According  to  Imrnelinann  (Zeils  f.  artz.  Fortbildung,  1904  No.  5.).  in  30  percent,  of 
normal  individuals  a  scKamoid  bone  may  be  found  beneath  the  external  head  of  the 
gastrocnemius  muscle  that  might  on  an  i-ray  examination  be  mistaken  for  a  loose  body 
within  the  joint. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT    437 

and  synovial  effusion.  The  accident  having  once  occurred,  is 
likely  to  recur;  the  patient  recognizing  the  character  of  the  move- 
ments that  are  likely  to  cause  the  displacement,  also  the  proper 
manipulation  for  its  replacement. 

Injury. — In  other  instances  somewhat  similar  symptoms  may 
follow  injury  at  the  knee,  pinching  of  the  synovial  membrane, 
bruising  or  fracture  of  the  cartilage,  or  a  strain  of  one  of  the 
ligaments  within  the  joint,  being  assigned  as  causes.  In  cases  of 
this  character,  in  which  symptoms  recur  from  time  to  time,  the 
joint  becomes  weak  and  insecure,  partly  because  of  the  repeated 
synovial  effusion  and  partly  because  of  the  muscular  relaxation. 

Treatment. — If  the  patient  is  seen  immediately  after  the  dis- 
placement or  injury  the  limb  should  be  fixed  in  a  plaster  bandage 
for  four  weeks  or  more  to  allow  for  reattachment  of  the  displaced 
part.  Afterward  the  joint  may  be  protected  by  the  adhesive  plaster 
strapping,  and  when  the  effusion  has  been  absorbed  massage  and 
exercises  for  strengthening  the  muscles  should  be  employed. 

In  the  more  chronic  cases  in  which  the  ligaments  are  lax,  a 
brace  which  will  permit  anteroposterior  motion,  but  prevent 
lateral  mobility,  may  be  required.  The  Campbell  brace  (Fig. 
193),  used  by  Shaffer,  is  a  light  and  effective  support  that  inter- 
feres little,  if  at  all,  with  the  use  of  the  limb. 

If  the  diagnosis  of  displaced  or  fractured  cartilage  can  be 
verified,  and  if  it  is  the  cause  of  persistent  disability,  it  should 
be  removed.  And  the  same  may  be  said  of  isolated  foreign 
bodies  which   are  known  to  be  the  cause  of  the  symptoms. 

Under  the  Esmarch  bandage  the  joint  is  opened  by  an  incision 
about  three  inches  in  length  on  the  anterolateral  and  internal 
aspect  of  the  joint.  After  the  capsule  is  opened  the  leg  is  flexed 
to  bring  the  cartilage  into  view.  If  loose  it  is  then  separated 
from  its  attachments  with  a  tenotomy  knife  and  is  removed.  The 
capsule  is  then  united  with  a  fine  catgut,  the  wound  is  closed,  and 
a  plaster  bandage  is  applied.  At  the  end  of  a  week  or  more  the 
patient  may  walk  about.  At  the  end  of  a  month  the  adhesive 
plaster  strapping  may  replace  the  bandage  or  preferably  in  cases 
of  long  standing  the  Campbell  brace  may  be  applied.  Perfect 
functional  recovery  is  the  ride. 

Hyperplasia. 

Hyperplasia  of  Fatty  Tissue  within  the  Joint. — The  largest  of  the 
pads  of  fibrofatty  tissue  witiiin  the  knee-joint  is  of  a  somewhat 


438  OR  TH  OPE  Die  SURGERY 

triangular  form,  its  base  lying  in  the  interval  between  the  femur  and 
the  tibite,  its  apex  projecting  upward,  held  between  the  femoral 
condyles  by  the  ligamentum  patellfe  and  the  ligamentum  mucosum. 
This  may  become  enlarged  and  sensitive  to  motion  and  pressure. 
In  such  cases  a  somewhat  sensitive  swelling  appears  on  either 
side  of  the  patella  and  its  ligament.  The  patient  suffers  from 
discomfort  particularly  on  changing  from  a  position  of  rest  to 
acti\dty  and  from  creaking  sensations  or  even  interference  with 
motion.  At  times  synovitis  may  be  present.  If  the  sjmiptoms 
are  not  relieved  by  rest,  strapping  or  other  conservative  treatment, 
the  removal  of  the  hypertrophied  tissue  is  indicated.  Sensitive 
tumors  of  a  similar  nature  may  appear  in  other  parts  of  the  joint 
and  folds  or  masses  of  hypertrophied  synovial  membrane,  the 
effect  usually  of  repeated  inflammation  may  induce  similar  symp- 
toms. In  such  cases  exploration  of  the  joint,  for  the  purpose  of 
ascertaining  the  cause  of  the  symptoms  or  for  removal  of  the 
obstructing  parts,  is  indicated. 

Incidental  Synovitis. 

Strains  of  the  knee-joint  slight  in  degree  may  be  induced  by 
genu  valgum,  by  slipping  patella  and  the  like,  and  discomfort  is 
not  infrequently  an  accompaniment  of  the  weak  foot.  It  may 
be  stated  also  that  simple  over- weight  or  strain,  as  for  example, 
laborious  work  in  fat  subjects,  may  induce  discomfort,  creaking 
sensations,  and  slight  effusion  in  the  joint.  In  fact,  over-weight 
is  the  most  constant  of  all  the  aggravating  causes  of  weakness  in 
the  knees  of  the  character  indicated.  Reduction  of  weight  by 
proper  diet  is  therefore  an  important  indication  for  treatment. 

"Quiet  Effusion." 

Painless  synovitis  at  the  knee  or  other  joints  is  sometimes 
observed  in  young  girls.  It  has  apparently  some  connection 
with  menstrual  irregularites.  Recurrent  effusion  of  a  similar 
character  in  one  or  both  knees  is  occasionally  seen  in  older  subjects. 
Without  appreciable  cause  and  at  fairly  regular  intervals  the 
joint  is  filled  with  fluid,  the  principal  discomfort  being  the  tension. 
The  swelling  persists  for  several  days  and  disappears.  In  the 
intervals  the  j(;int  appears  to  be  normal  except  for  a  certain  laxity 
of  the  ligaments. 

Attention  is  again  called  to  the  fact  that  chronic  synovitis  con- 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT    439 

fined  to  a  single  joint  which  shows  no  tendency  to  improvement 
is  often  tuberculous  in  character/ 

One  case  has  come  under  my  observation  and  eight  others  are 
reported,  in  but  one  of  which  was  there  general  dissemination  of 
the  disease. 

Other  forms  of  synovitis  or  joint  disease  dependent  upon 
general  constitutional  causes  or  upon  direct  infection  have  been 
considered  in  Chapter  VI. 

Prepatellar   Bursitis. 

Synonym. — Housemaid's  knee. 

A  chronic  enlargement  of  the  bursa  lying  over  the  patella  and 
its  ligiment  is  common  among  those  who  have  to  kneel  much 
of  the  time;  hence  the  popular  name.  Occasionally  cases  of  acute 
bursitis,  in  which  there  is  considerable  effusion  into  the  sac,  are 
seen,  and  these  are  sometimes  mistaken  for  synovitis  of  the  knee. 

Treatment. — In  acute  cases  strapping  the  front  of  the  knee 
with  strips  of  adhesive  plaster  which  will  limit  motion  and 
provide  compression  is  an  effective  treatment.  If  the  effusion  is 
considerable  it  may  be  relieved  by  aspiration  or  incision.  In 
chronic  cases  cure  can  be  attained  only  by  the  removal  of  the 
thickened  sac. 

Pretibial   Bursitis. 

Beneath  the  ligamentum  patellae,  occupying  the  space  between 
the  tendon  and  the  periosteum  of  the  tibia,  is  the  deep  pretibial 
bursa.  It  is,  according  to  the  investigations  of  Lovett,^  as  wide 
or  somewhat  wider  than  the  tendon;  its  upper  border  is  on  a 
level  with  the  joint,  its  lower  border  reaches  to  the  tuliercle  of 
the  tibia,  and,  being  slightly  longer  on  the  outer  than  on  the 
inner  border,  it  is  somewhat  triangular  in  shape.  It  does  not 
communicate  with  the  knee-joint. 

Enlargement  of  this  bursa  is,  as  a  rule,  the  result  of  injury, 
but,  as  bursitis  elsewhere,  it  may  be  a  complication  of  infectious 
diseases,  rheumatism  and  the  like. 

Symptoms. — The  symptt)ms  are  stiffness  at  the  knee  and  pain 
on  sudden  movement,  especially  when  strain  is  exerted  on  the 
tendon  by  complete  flexion  or  extension  of  the  leg  as  in  active  use. 

'  In  rare  instances  primary  sarcoma  of  the  capsule  may  cause  chronic  synovitis.  The 
principal  diagnostic  points  are  the  local  or  general  thickeninR  of  the  capsule  and  the  blood- 
stained fluid  obtained  on  aspiration.  The  course  of  the  disease  is  very  chronic  and 
its  malignancy  is  slight.  Thorough  removal  of  the  capsule  with  or  without  excision  would 
seem  to  be  indicated. 

-  Boston  City  Hospital  Reports,  1897,  Sth  series. 


440  ORTHOPEDIC  SVEGERY 

The  tubercle  of  the  tibia  seems  enlarged  and  is  sensitive  to  pres- 
sure, and  a  swelling  on  either  side  of  the  ligament  is  usually  ^  vident. 
Treatment. — The  affection,  if  at  all  acute,  may  be  treated  by 
relievmg  the  strain  and  pressure  on  the  tendon,  by  fixation  of 
the  limb  for  a  time  in  a  plaster  bandage  or  other  form  of  splint. 
Later  the  adhesive  plaster  strapping  will  provide  sufficient  fixa- 
tion and  pressure.  The  absorption  of  the  fluid  may  be  hastened 
by  the  application  of  the  cautery.  If  the  swelling  is  persistent, 
the  fluid  may  be  removed  by  aspiration  or  incision  or  removal 
of  the  sac. 

Enlargement  of  the  Superficial  Pretibial  Bursa. 

A  small  bursa,  lying  upon  the  insertion  of  the  ligamentum 
patellae,  may  become  enlarged,  causing  an  apparent  hypertrophy 
of  the  tubercle  of  the  tibia.  It  may  be  treated  by  strapping  with 
adhesive  plaster,  and  the  prominent  tubercle  should  be  protected 
by  some  form  of  bunion  plaster. 

Injury  of  the  Tibial  Tubercle. 

Osgood^  has  called  attention  to  the  fact  that  symptoms  resem- 
bling those  described  may  be  caused  by  partial  separation  of  the 
tubercle  of  the  tibia.  The  treatment  is  primarily  rest  in  the 
extended  attitude. 

Burs 88  and  Cysts  in  the  Popliteal  Region. 

Simple  inflammation  of  the  bursa  lying  between  the  inner  head 
of  the  gastrocnemius  and  the  semimembranosus  muscle  may  cause 
a  fluctuating  swelling  on  the  inner  side  of  the  popliteal  region. 
It  may  be  treated  by  compression,  by  incision,  or  by  complete 
removal  as  may  seem  advisable.  Cysts  in  the  popliteal  region 
usually  communicate  with  the  knee-joint  and  are  complications 
of  rheumatic  or  tuberculous  disease.  In  such  cases  they  are  of 
interest  principally  from  the  diagnostic  standpoint. 

Acquired  Genu  Recurvatum. 

Synonym. — Back  knee. 

Genu  recurvatum,  as  the  name  implies,  is  a  deformity  in  which 
the  knee  is  habitually  overextended. 

1  BoHton  Medical  and  Surgical  Journal,  January  29,  1903. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT     441 

Etiology. — Acquired  genu  recurvatum  may  be  a  simple  local 
deformity,  or  it  may  be  secondary  to  weakness  or  distortion  of 
other  parts.  Local  or  primary  genu  recurvatum  may  be  an  effect 
of  rhachitis,  or  of  disease  or  injury  of  the  femur  or  tibia.  In 
this  form  the  femur  may  be  curved  sharply  forward  above  the 
joint,  or  the  upper  extremity  of  the  tibia  may  be  bent  backward 
at  the  epiphyseal  junction,  and  flexion  may  be  limited  by  the 
obliquity  of  the  articulating  surfaces. 

More  often  the  deformity  is  secondary.  It  may  be,  for  example, 
an  effect  of  equinus,  either  congenital  or  acquired,  in  which 
the  knee  is  strained  by  the  effort  of  the  patient  to  place  the  heel 
upon  the  ground.  It  may  be  caused  by  the  use  of  a  brace  in 
the  treatment  of  hip  disease,  if  the  knee-joint  is  not  properly 
supported,  and  it  is  often  seen  also  as  a  result  of  disease  at  this 
joint,  for  which  no  apparatus  has  been  employed.  It  even 
appears  in  some  instances  on  the  sound  side,  apparently  as  a  form 
of  compensation  for  the  shorter  limb  (Fig.  206).  It  is  one  of  the 
comparatively  infrequent  complications  of  disease  at  the  knee- 
joint,  for  which  the  leg  has  been  supported  by  the  brace  in  an 
extended  or  overextended  position,  or  in  which  the  growth  at  the 
epiphyseal  cartilages  of  the  femur  or  tibia  has  been  irregular. 
In  rare  instances  it  is  the  direct  result  of  traumatism,  as  when 
the  limb  has  been  suddenly  forced  into  an  overextended  position, 
and  the  posterior  ligaments,  and  possibly  the  crucial  ligaments, 
also,*  have  been  ruptured  or  weakened.  It  is  most  often,  however, 
an  accompaniment  of  paralysis  of  the  posterior  thigh  muscles  or 
of  the  gastrocnemius  muscle,  or  both.  A  slight  degree  of  over- 
extension at  the  knees  is  not  uncommon  in  children  who  have 
the  so-called  loose  joints. 

In  many  cases  genu  recurvatum  is  combined  with  a  varying 
degree  of  knock-knee,  and  there  is  often  an  abnormal  mobility  at 
the  joint  that  allows  a  certain  amount  of  posterior  displacement 
of  the  tibia.  In  extreme  cases  of  this  class  there  may  be  well- 
marked  subluxation. 

Symptoms. — The  symptoms,  aside  from  the  deformity,  are 
weakness  and  insecurity  caused  by  the  hyperextension  when 
weight  is  borne.  If  the  deformity  is  extreme,  the  strain  upon 
the  weakened  parts  usually  causes  discomfort.  Flexion  is  ren- 
dered difficult  because  of  the  abnormal  relation  of  the  joint  sur- 
faces and  by  the  accommodative  changes  in  the  ligaments  and 
muscles,  so  that  in  extreme  cases  the  patient  swings  the  k^g  along 
in  the  extended  or  overextended  position. 


442 


ORTHOPEDIC  SURGERY 


Treatment. — ^If  the  recurvation  is  caused  by  deformity  of  the 
bones,  the  normal  relations  may  be  restored  by  osteotomy  of  the 
tibia  or  femur,  as  may  be  indicated.  Deformity  secondary  to  dis- 
tortions elsewhere  may  be  treated  by  remedying  the  primary  cause. 

Traumatic  genu  recurvatum  may  be  treated  by  fixation  in  the 
flexed  position  .until  the  repair  is  complete,  afterward  by  massage 
and  support  if  necessary.  The  ordinary  form  of  overextended 
knee,  combined  T\'ith  lateral  mobility,  must  be  supported  by  a 
brace  which  permits  only  anteroposterior  motion  to  the  normal 
limit  or  slightly  less,  ^^^lenever  possible  massage  and  exercises 
should  be  employed. 

Congenital  Genu  Recurvatum. 

Synonym. — Anterior  displacement  of  the  tibia. 

The  most  common  of  the  congenital  deformities  at  the  knee  is 
the  so-called  genu  recurvatum,  in  which  the  knee  is  bent  some- 
what backward;    or,  in  other  words,  the  leg  is  hyperextended  on 

Fig.  284 


Congenital  genu  rcuurvutum.     (ITofTa.) 

the  thigh.  Tlic  condition  is  often  spoken  of  as  an  anterior  dis- 
location, but  there  is  no  actual  displacement,  except  in  the  extreme 
cases  in  which  the  tibia  may  be  turned  directly  forward  on  the 
femur,  even  to  a  right  angle  or  less.  In  the  ordinary  cases  the 
range  of  extension  is  merely  exaggerated,  while  flexion  is  limited 
or  checked,  principally  by  adaptive  shortening  of  the  quadriceps 
exten.sor  muscle  (Fig.  284 j.     In  some  cases  there  may  be  changes 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT    443 

in  the  direction  of  the  articulating  surfaces  in  adaptation  to  the 
deformity  of  the  femur  and  tibia/ 

The  appearance  in  well-marked  genu  recurvatum  Ls  very 
peculiar;  it  is  as  if  the  patient's  leg  were  reversed,  for  the  popliteal 
depression  has  become  a  prominence  and  the  range  of  overexten- 
sion seems  to  represent  normal  flexion.  In  such  cases  the  leg 
may  be  brought  to  the  straight  line,  but  greater  flexion  is  resisted 
by  the  retracted  tissues,  and  when  the  pressure  of  the  hand  is 
removed  the  leg  is  drawn  back  to  the  deformed  position  by  the 
contraction  of  the  quadriceps  extensor  muscle. 

Other  Deformities  and  Malformations. — Genu  recurvatum  is  not 
infrequently  accompanied  by  varus  or  valgus  deformity  at  the 
knee,  more  often  by  the  latter,  and  by  laxity  of  the  ligaments. 
In  many  instances  the  patella  is  absent  or  is  rudimentary,  and  not 
infrequently  the  deformity  is  accompanied  by  malformations  or 
defective  development  of  other  parts. 

Seventy-eight  cases  were  collected  by  Potel.^  In  37  instances 
the  deformity  was  limited  to  one  side;  in  the  others  both  limbs 
were  affected.  In  50  cases  the  condition  of  the  patella  was  noted; 
in  26  of  these  it  was  absent  or  rudimentary.  Twenty  of  the  cases 
were  accompanied  by  talipes. 

Etiology. — The  deformity  in  cases  of  simple  recurvatum  may 
be  explained  by  an  abnormal  and  fixed  position  in  utero,  and  in 
cases  seen  soon  after  birth  the  mechanism  is  clearly  shown  by  the 
habitual  attitude.  The  thighs  are  sharply  flexed  on  the  body; 
the  dorsal  surfaces  of  the  hyperextended  knees  are  in  relation 
to  the  abdomen,  while  the  feet  may  be  brought  into  contact  with 
the  face  or  trunk,  according  to  the  degree  of  deformity.  The 
retarded  development  of  the  quadriceps  extensor  muscle  explains 
the  rudimentary  patella  which  is  often  an  accompaniment  of  the 
deformity. 

-  Treatment. — The  treatment  of  the  hyperextended  knee  is  very 
simple.  It  consists  in  massage  of  the  atrophied  and  contracted 
muscles,  combined  with  more  or  less  forcible  manipulation  in  the 
direction  of  flexion.  If,  as  is  often  the  case,  the  leg  seems  to  be 
drawn  forward  by  spasmodic  muscular  action,  the  methodical 
massage  should  be  combined  with  the  use  of  a  simple  posterior 
splint. 

In  the  more  extreme  cases  manual  force  may  be  applied  under 
anaesthesia,  and  the  deformity  may  be  overcome  at  one  or  several 

'   Delanglade,  Eevue  d'Orthopddie,  May,   1903. 

-  Etude  sur  les  Malformations  Congcnitale  du  Genou.     Lille,  1S97,  Imp.  L.  Daniel. 


444  ORTHOPEDIC  SURGERY 

sittings,  according  to  the  resistance  of  the  contracted  parts.  The 
limb  is  then  fixed  in  a  flexed  position  until  the  tendency  to  recur- 
rence has  been  overcome.  ^Mien  the  child  begins  to  walk  a  light 
lateral  brace  may  be  necessary  to  ensure  perfect  functional  use  of 
the  joint,  as  in  many  instances  laxity  of  ligaments  and  muscidar 
weakness  may  persist  for  a  long  time. 

Rudimentary  or  Absent  Patella. 

As  has  been  stated,  a  rudimentary  patella  is  a  frequent  com- 
plication of  genu  recurvatum  or  of  any  congenital  defect  or  de- 
formity of  the  knee  or  limb  that  involves  imperfect  development 
of  the  quadriceps  extensor  muscle.  In  many  cases  of  this  type 
it  is  impossible  to  distinguish  the  patella  during  the  early  months 
of  infancy,  but  later  a  minute  patella  appears  that  slowly  in- 
creases to  an  approximately  normal  size. 

Absence  of  patella  under  the  same  conditions  is  less  frequent, 
although  Potel  collected  one  hundred  cases  from  literature. 

Treatment. — The  treatment  of  rudimentary  patella  is  included 
in  the  massage  and  stimulation  of  the  atrophied  or  rudimentary 
muscle  with  which  it  is  usually  associated,  and  the  support  that 
the  weak  or  deformed  knee  may  require. 

Congenital  and  Acquired  Displacement  of  the  Patella. 

The  patella  may  be  displaced  upward  as  a  result  of  extreme 
genu  recurvatum,  and  in  rare  instances  it  may  be  displaced  inward 
or  downward,  but  far  more  often  the  displacement  is  outward. 
Fifty  cases  of  this  form  are  recorded,  in  most  of  which  it  was  a 
complication  of  congenital  genu  valgum. 

Acquired  complete  displacement  in  which  the  patella  lies  on 
the  outer  aspect  of  the  external  condyle  is  most  often  an  accom- 
paniment of  extreme  genu  valgum.  The  first  step  in  treatment 
must  be  to  remedy  the  distortion  of  the  limb,  but  if  the  deformity 
Is  of  long  duration  the  tissues  on  the  anterior  aspect  will  have 
become  so  shortened  that  flexion  will  be  much  limited. 

Slipping  Patella. 

This  terra  is  applied  to  an  abnormal  laxity  of  the  supporting 
tissues  that  allows  occasional  displacement  of  the  patella  upon 
or  to  the  outer  side  of  the  external  condyle. 


NON-TUBERCULOUS  AFFECTIONS  OF  KNEE-JOINT    445 

Etiology.— This  disability  is  more  common  among  females 
than  males,  and  is  more  often  unilateral  than  bilateral.  The 
abnormal  mobility  may  be  an  inherited  peculiarity;  it  may  be 
due  to  weakness  of  the  quadriceps  extensor  muscle,  or  to  imper- 
fect development  of  the  patella  or  of  the  external  condyle;  or  the 
original  displacement  may  have  been  due  to  injury.  In  many 
instances,  however,  the  predisposing  cause  is  genu  valgum,  as  a 
consequence  of  which  the  patella  is  carried  toward  the  external 
condyle.  Slight  occasional  displacement  sufficient  to  cause 
discomfort  is  a  not  uncommon  accompaniment  of  weak  feet, 
which  indicates  as  a  rule  muscular  weakness  or  relaxation. 

Fig.   285 


Slipping  patella  of   the  left  side. 

Weimuth^  has  collected  66  cases.  Of  these  32  were  of  con- 
genital, 14  of  traumatic  (rupture  of  internal  ligaments),  and  20 
of  pathological  origin  (knock-knee). 

•  Symptoms. — If  the  slipping  of  the  patella  is  a  frer|uent  occur- 
rence it  causes  comparatively  little  pain,  but  when  the  parts  are 
less  relaxed  the  displacement  is  likely  to  be  followed  by  a  certain 
amount  of  effusion  into  the  joint  and  by  the  symptoms  of  a  sprain. 
It  is  usually  the  result  of  a  misstep  or  sutlden  movement  when 


1  Deutsche  Zeits.  f.  Chir.,  Bd.  Ixi.     Bade,  Zeits.  f.  Orthop.  Chir.,  1903.  Bd.  xi.  p.  3. 


446  ORTHOPEDIC  SURGERY 

the  thigh  muscle  is  relaxed  or  of  extreme  flexion  of  the  leg.  As 
a  rule,  there  is  a  sense  of  insecurity  and  weakness  at  the  knee  in 
those  who  are  subject  to  the  accident. 

Treatment. — The  treatment  varies  according  to  the  condition 
of  the  parts  about  the  joint.  If  the  displacement  is  the  direct 
result  of  violence  the  leg  should  be  fixed  for  a  time  in  a  plaster 
bandage,  which  may  be  replaced  by  the  adhesive  plaster  strap- 
pmg  or  a  knee-cap.  This  improvement  of  the  muscular  tone  by 
exercises  is  always  an  important  part  of  treatment  whether  or 
not  support  is  employed.  In  cases  in  which  the  slipping  has 
become  habitual  and  particularly  when  the  ligaments  of  the 
joint  are  much  relaxed,  a  light  brace  should  be  employed  to  prevent 
lateral  motion  and  to  limit  the  range  of  flexion  at  the  joint,  if 
this  predisposes  to  the  displacement. 

Operative  Treatment.— If  the  position  of  the  patella  that  pre- 
disposes to  the  further  displacement  is  a  consequence  of  genu 
valgum  the  rectification  of  the  deformity  will,  as  a  rule,  remedy 
the  secondary  disability.  If  the  displacement  appears  to  be 
caused  by  laxity  of  the  capsular  ligament,  as  well  as  by  the  ab- 
normal position  of  the  patella,  an  operation  for  the  purpose  of 
limiting  the  mobility  and  restoring  the  proper  relation  of  parts 
may  be  conducted  in  the  following  manner:  A  long,  curved 
incision  is  made  about  the  inner  side  of  the  knee,  the  lower  ex- 
tremity of  which  crosses  the  ligamentum  patellae.  The  skin-flap 
having  been  reflected,  the  contracted  capsule  may  be  divided 
on  the  outer  side  without  disturbing  the  synovial  membrane.  The 
patella  is  then  forced  inward  and  the  redundant  tissue  on  the 
inner  side  is  folded  and  sutured,  or  a  section  of  the  capsule  may 
be  removed,  sufficient  in  size  to  hold  the  patella  in  its  proper 
position.  As  an  additional  safeguard  the  semimembranosus 
tendon  may  be  transplanted  to  the  inner  border  of  the  ligamen- 
tum patella?  as  suggested  by  Backer.^  In  extreme  cases  the 
tubercle  of  the  tibia,  with  the  attached  tendon,  may  be 
removed  and  reimplanted  on  the  inner  aspect  of  the  tibia,  as 
suggested  by  Wolff'  and  Walsham.  The  limb  should  be  held  in 
the  extended  po.sition  for  a  time,  and  it  should  afterward  be 
supported  by  a  brace  or  knee-cap  for  several  months.  Subse- 
quently massagf;  and  (;xercise  for  restoring  the  tone  of  the  weak- 
ened muscle  should  be  employed. 

>  Ze.it.  f.  Chir.,  1904,  No.  24 


NON- T  UBER  C  UL  0  US  A  FFECTIONS  OF  KNE E-JOIST    447 

Elongation  of  the  Ligamentum  Patellae. 

In  certain  cases  the  ligamentum  patella  may  be  abnormally 
long,  so  that  the  patella  lies  habitually  above  its  proper  position. 
This  elongation  may  be  one  of  the  evidences  of  general  relaxation 
of  the  ligaments  of  the  knee,  and  thus  a  predisposing  cause  of  the 
slipping  patella  or  of  abnormal  mobility  at  the  knee-joint. 

Etiology. — The  elongation  of  the  tendon  may  be  a  congenital 
peculiarity  or  it  may  be  acquired.  It  is  most  often  observed  as 
an  effect  of  anterior  poliomyelitis  or  of  hemiplegia  or  paraplegia. 

Symptoms. — The  symptoms  of  elongation  of  the  ligamentum 
patellae,  as  distinct  from  those  of  the  general  laxity  of  the  liga- 
ments that  is  often  present,  are  weakness  and  disability,  usually 
noticeable  on  walking  up  or  down  stairs,  or  after  overexertion. 
Shaffer,  who  first  called  attention  to  the  disability  from  this  cause, 
thinks  that  it  may  be  a  predisposing  cause  of  displacement  of  the 
semilunar  cartilages. ^ 

Treatment. — In  this,  as  in  other  forms  of  insecurity  or  of 
abnormal  mobility  at  the  knee,  a  brace  that  allows  only  antero- 
posterior motion  will,  as  a  rule,  relieve  the  symptoms.  If  the 
ligament  is  of  such  a  length  as  to  require  it,  it  may  be  shortened, 
or  the  tubercle  of  the  tibia  may  be  removed  and  implanted  at  a 
lower  point,  as  suggested  by  Walsham.^ 

Other  Congenital  Deformities  at  the  Knee. 

Congenital  displacements  are  uncommon.  As  a  rule,  they 
are  incomplete  and  are  caused  by  laxity  of  the  ligaments  and  by 
defective  formation  of  the  bones  or  other  parts. ^ 

Snapping  Knee. 

A  very  slight  form  of  partial  recurrent  displacement  is  the 
snapping  or  clicking  knee  not  uncommon  in  early  infancy,  in 
which  the  tibia  on  sudden  extension  of  the  limb  springs  forward 
or  rotates  outward  on  the  femur  with  an  audible  snapping  sound. 
This  movement  appears  to  be  the  result  of  voluntary  muscular 
contraction  combined  with  laxity  of  ligaments  and  very  possibly  with 
irregular  movements  of  one  or  other  of  the  semilunar  cartilages. 
In  some  instances  the  subluxation  appears  to  cause  pain  or  dis- 

'   Transactions  American  Orthopedic  Association,  vol.  xi. 

=  Medical  Weekly.  February  17,  1893. 

•'  Drehmann,  Die  Cong.  Lux.  des  Kniegelenks,  Zeits.  f.  Orth.  Chir.,  1900,  Bd.  vii.  H.  4. 


448  OR THOPEDIC  S UB  GER  Y 

comfort.  The  ability  to  displace  the  tibia  on  the  femur  by  mus- 
cular action  is  sometimes  found  in  older  subjects.  In  such  cases 
it  may  be  the  result  of  injury  such  as  rupture  of  ligaments  or 
irregidarity  within  the  joint.  Occasionally  the  snapping  may  be 
caused  by  slipping  of  the  biceps  tendon. 

Treatment. 7— The  treatment  of  congenital  dislocations  or  sub- 
luxations of  the  knee  consists  in  reposition,  support,  and  massage 
of  the  weak  part.  The  snapping  knee  may  be  supported  by  a 
flannel  bandage,  or,  in  the  more  marked  type  of  laxity  of  liga- 
ments, it  may  be  fixed  for  a  time  in  a  brace.  Complete  recovery 
is  the  rule. 

Congenital  Contraction  at  the  Knee. 

Slight  limitation  of  the  range  of  extension  of  one  or  both  knees 
is  not  infrequent.  As  a  rule,  it  is  easily  overcome  by  massage 
and  manipulation.  In  the  more  extreme  cases  there  may  be  an 
accommodative  forward  bending  of  the  lower  extremity  of  the 
femur,  as  in  certain  cases  in  which  flexion  follows  anchylosis. 

General  Contractions. 

Congenital  contraction  at  the  knees  of  a  more  marked  and 
resistant  form  may  be  combined  with  flexion  contraction  at  the 
hips,  or  it  may  be  one  of  a  series  of  contractions  at  other  joints. 
In  the  latter  instance  other  congenital  deformities,  such  as  club- 
hand or  foot,  or  evidences  of  defective  development  are  usually 
present.  For  example,  certain  joints  may  be  fixed  in  flexion  or 
fixed  in  extension.  In  some  instances  the  contraction  or  the  par- 
tial anchylosis  appears  to  be  due  simply  to  long-continued  fixation 
in  utero,  and  to  consequent  non-development  of  the  muscles.  In 
others  it  appears  to  be  a  complication  of  so-called  foetal  rhachitis. 

Treatment. — The  treatment  consists  in  regular  massage  and 
manipulation,  with  the  aim  of  increasing  the  range  of  motion. 
Deformity,  if  present,  may  be  rectified  in  the  usual  manner. 

Prognosis. — The  prognosis  depends  upon  the  cause  of  the  con- 
traction or  fixation.  In  most  instances,  under  careful  and  con- 
tinued treatment,  the  range  of  motion  may  be  in  great  degree 
restored. 


CHAPTER    XI. 

DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT. 

Tuberculous  Disease  of  the  Ankle-joint. 

Disease  of  the  ankle-joint  is  the  third  in  the  order  of  impor- 
tance, although  it  is  far  less  common  than  is  disease  at  the  knee. 

In  five  consecutive  years  1788  cases  of  tuberculous  disease  of 
the  joints  of  the  lower  extremity  were  treated  at  the  out-patient 
department  of  the  Hospital  for  Ruptured  and  Crippled.  In  54.1 
per  cent,  of  these  the  hip-joint  was  affected;  in  36.2  per  cent, 
the  knee-joint,  and  in  but  9.7  per  cent,  the  ankle-joint. 

Fig.   286 


Tuberculous  disease  of  the  ankle  and  tarsus.     A,  disease  of  the  ankle  and  subastragaloid 
joints.     B,  cavity  in  the  os  calcis  containing  sequestrum. 

Pathology. — The  pathology  of  tuberculous  disease  at  the  ankle 
differs  in  no  essential  particular  from  that  of  disease  of  the  hip 
and  knee.  It  does  not,  therefore,  call  for  special  consideration. 
It  is  of  interest  to  note,  however,  that  abscess  is  a  more  common 
complication  at  this  than  at  the  other  joints. 

In  30  final  results  of  disease  at  the  ankle  reported  by  Gibney,* 

'  Anierican  Journal  of  Obstetrics,  .\pril,  1880. 
29 


450  OBTHOPEDfC  SURGERY. 

abscess  was  present  in  25  (S3  per  cent.).  In  7S  final  results 
reported  by  Prendlsburger^  abscess  was  present  in  68  (87  per 
cent.),  as  contrasted  with  a  percentage  of  69  and  51  at  the  knee 
and  hip,  respectively.  This  greater  liability  to  abscess  is  very 
possibly  apparent  rather  than  actual,  since  the  ankle-joint  is  so 
superficial  that  fluctuation  may  be  detected  here  that  would  be 
overlooked  at"  the  hip.  And  because  the  tissues  about  the  joint 
readily  allow  spontaneous  opening  at  an  early  period,  before 
sufficient  time  has  elapsed  to  permit  of  spontaneous  absorption. 

Situation  of  the  Disease. — Otto  Hahn"  investigated  the  cases 
of  tuberculous  tlisease  of  the  ankle  and  foot  treated  at  Tubingen 
during  a  period  of  fifteen  years.  These  cases  were  704  in  number 
in  685  patients,  in  19  both  feet  having  been  involved. 

In  309  of  the  cases  the  disease  was  of  the  ankle-joint.  Of 
these  51  per  cent,  were  osteal  in  origin.  The  primary  focus  was 
in  the  internal  malleolus  in  11,  the  external  in  7,  in  both  in  5. 
It  was  in  the  astragalus  in  116  cases. 

In  16  instances  the  disease  of  the  ankle  was  secondary  to  pri- 
mary infecticn  of  the  os  calcis,  and  in  5  cases  both  the  astragalus 
and  the  os  calcis  were  diseased. 

Of  88  eases  investigated  by  Stich^  the  ankle-joint  was  involved 
in  88  per  cent.,  in  45  per  cent,  the  disease  being  limited  to  this 
joint.  The  astragalo-na^  icular  joint  was  involved  in  29  per 
cent.,  and  the  astragalo-calcaneoid  joint  in  36  per  cent. 

Etiology. — The  etiology  of  tuberculous  joint  disease  does  not 
require  further  comment.  It  may  be  noted,  however,  that  tuber- 
culous disease  at  the  ankle  is  relatively  more  common  in  later 
childhood  and  adidt  life  than  is  the  same  affection  at  the  knee 
and  hip. 

Of  1000  cases  of  disease  of  the  hip-joint,  12  per  cent,  were  in 
patients  more  than  ten  years  of  age. 

Of  1000  cases  of  disease  of  the  knee-joint,  25  per  cent,  were 
in  patients  mcjre  than  ten  years  of  age. 

Of  339  eases  of  disease  of  the  ankle-joint,  30  per  cent,  were 
in  patients  more  than  ten  years  of  age."* 

C)f  the  339  patients  177  were  males  (52.2  per  cent.);  162  were 
females  (47.8  per  cent.).  The  disease  was  of  the  right  ankle 
in  173  cases;  of  tlic  left  in  166. 

•  Loc.  cit.  "   HeitrilKfiztiikliti.  Chir.,  l'J()(),  Hil.  xxvi.,  U.  2. 
3  Beit.  z.  klin.  Chir.,  lid.  xlv.,  p.  .'587. 

*  HtatiMtioH  froiii  Hospital  for  Hu|>lurc(l  ami  Ciipplcd. 


DlSEAi>ES  AND  INJURIES  OF  THE  ASKLE-.JOINT      45I 


Age  at  Incipiency  of  Axkle-joint  Disease  ix  339  Consecutive  Cases 
Treated  at  the  Hospital  for   Huptuhed  and  rnippT.ED. 

1  year  or  less 5          24  years  old 2 

2  years  old 42          25       "".......  3 

3  "       " 43          26       "       " 3 

4  "       " 44         27       "       " 4 

5  "       " 34         28       "       '• 4 

6  "        " 24          29        "        " 2 

7  "       " 19          30       "       '• 2 

8  "       " 8          31        "       •' 0 

9  "       " 9          32       "       " 1 

10  "       " 9          33       "       " 2 

11  "       " 11          34       "       •■ 1 

12  "       " 8          35       "        '• 0 

13  "       " 4          36       "       " 2 

14  "       " 4          37        "       "            2 

15  "       " 4          40       "       •■ 4 

16  "       " 6          43       "       " 1 

17  "       " 2          44       "       •■ 1 

18  "       " 4          45       "       " 4 

19  "       " 3          46       "       " 2 

20  "       "        3          48       "       " 1 

21  "       " 4         50       "        " 1 

22  "       " 5 

23  "        " 2  339 

Of  658  patients  412  were  males  (62  per  cent.);  246  were  females 
(38  per  cent.).     In  27  the  sex  was  not  stated. 

Age  of  the  Patients  Treated  for  Ankle-joint  and  Tarsal 
Disease  at  Tubingen.     (Hahn.) 


1  to 

10  years 

11  " 

20   " 

21  " 

30   " 

31  " 

40   " 

41  " 

50   " 

51  " 

60   " 

61  " 

70   " 

71  " 

80   " 

81   " 

Males. 

Females. 

Total. 

45 

28 

73 

149 

91 

240 

89 

34 

123 

32 

28 

60 

37 

27 

64 

35 

26 

61 

18 

11 

29 

6 

1 

7 

1 

0 

1 

412 

246 

658 

Symptoms. — The  symptoms  are  usually  suhr.cute  in  character, 
and  are  often  mistaken  for  sprain  or  rlicumatism.  In  some 
instances  they  appear  to  follow  an  injury,  hut  in  the  majority  of 
cases  in  childhood  no  cause  can  he  assigned.  The  ankle  hecomes 
sensitive  to  sudden  movements;  the  patient  limps,  and  discomfort 
after  overuse  and  pain  at  night  become  nuticeahle.  The  limp 
differs  in  character  from  that  caused  by  hip  or  knee  disease. 
The  patient  walks  with  the  foot  rotated  outward,  bearing  the 
weight  upon  the  heel  and  upon  the  iimer  border,  active  leverage 
"spring"  being  avoided. 


452 


ORTHOPEDIC  SURGERY 


Deformity. — The  primary  deformity  of  ankle-joint  disease  in 
the  subacute  cases  is  A'algus,  induced  apparently  by  the  continued 
use  of  the  limb  in  the  passive  attitude.  In  more  advanced  cases 
it  becomes  equinovalgus,  and  when  the  limb  is  no  longer  capable 
of  supporting  weight,  but  is  held  pendent,  the  equinus  edmriofty 
predominates,,  due  partly  to  the  force  of  gravity  and  partly  to  the 
muscular  spasm. 

Fig.  287 


IB 

'■■•'^^^^^SSm^k. ''*'"'"* 

''■'*"*'•"  '^  ' 

W 

i 

1 

Tuberculous  disease  of  the  ankle. 

As  has  been  stated,  in  the  early  stage  the  symptoms  are  those 
of  a  persistent,  somewhat  painful  disability  at  the  ankle,  causing 
stijjness,  limp,  and  at  times  pain;  later  swelling  and  deformity 
appear. 

Physical  Examination. — The  joint  is  usually  somewhat  enlarged. 
In  some  instances  the  swelling  is  uniform;  in  others  it  is  localized 
in  front  or  behind  one  of  the  malleoli.  This  swelling  is  not, 
as  a  rule,  like  that  of  simple  effusion  into  the  joint,  but  the  tissues 
have  the  peculiar  elasticity  characteristic  of  thickening  and  infiltra- 
tion. There  is  usually  a  perceptible  increase  in  the  local  tem- 
perature, and  pressure  directly  upon  the  malleoli  causes  dis- 
comfort,    'i'lie  voluntary  movements  of  the  joint  are  restricted, 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT      453 

and  passive  movements  show  the  characteristic  reflex  muscular 
spasm,  Hmiting  both  dorsal  and  plantar  flexion. 

Subastragaloid  Disease.— If  the  astragalus  is  primarily  diseased, 
the  symptoms  are  usually  first  apparent  in  the  ankle-joint,  but  in 
certain  cases  the  joint  between  the  astragalus  and  the  os  calcis  is 
first  involved,  the  primary  focus  being  in  the  os  calcLs,  Disease 
at  the  subastragaloid  joint  is  usually  classed  as  ankle-joint  disease, 
although  the  swelling  is  most  marked  at  a  point  somewhat  below 
the  malleoli  (Fig.  288). 

Fig.  288 


Tuberculous  disease  of  the  subastragaloid  joint. 

In  this  form  forced  lateral  motion  of  the  os  calcis  causes  dis- 
comfort, and  the  range  of  adduction  and  abduction  of  the  foot 
is  restricted,  while  dorsal  and  plantar  flexion  may  remain  com- 
pletely free. 

Astragalo-navicular  Disease. — In  this  form  the  foot  is  held  in 
an  attitude  of  persistent  abduction  and  if  the  disease  is  subacute 
it  may  be  mistaken  for  rigid  weak  foot. 

Diagnosis. — The  principles  of  difterential  diagnosis  of  tuber- 
culous disease  from  other  aft'ections  have  been  considered  in 
detail  in  the  description  of  disease  of  the  spine  and  of  the  larger 
joints. 


Fig.    2S9 


'ITie  epiphyMf!,'*  <  f  itic  lowir  exlrfirnilit^f^  nl  \\if  -.iv.'-  "I  >i^  ycu^,  sljowiiiK  the  effect  of  oper- 
ative removal  of  hone  at  the  ankle-joint  for  t  uhctcijloim  ilisoasc  at  tlie  iiKe  of  three  years,  in 
cauHinK  Hub«ef4iient  deformity  til  the  foot  and  xhorteniriK  of  the  limb.  OHHification  is  preHcnt 
at  birth  in  the  lower  epiphyHiH  of  the  tihiii.  It  bcKiiiM  ;it,  tho  socond  year  in  the  lower 
epiphysiH  of  the  fibilhi,  but   not.  until  th<-  tilth  your  in  its  U|ip<T  i'|ii|)liysiH. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT     455 

In  childhood  a  chronic,  ])ainful  disease  confined  to  a  single 
joint  in  which  motion  is  limited  by  muscular  spasm,  and  in  which 
there  is  a  tendency  to  deformity,  is  almost  certainly  tuberculous 
in  character. 

In  adult  life  also  the  same  statement  applies,  and  distinguishes 
tuberculous  disease  from  rheumatism,  rheumatoid  arthritis,  or  other 
general  affections.  Forms  of  infectious  arthritis  may  be  differ- 
entiated by  the  history.  Sprains  or  other  injury  may  be  distin- 
guished by  the  history  of  the  onset  and  by  the  absence  of  local 
signs  of  serious  disease.  In  rigid  flat-foot  the  symptoms  are  local- 
ized at  the  mediotarsal  joint.  It  should  be  borne  in  mind,  also, 
that  the  pain  from  a  weak  or  injured  foot  is  experienced,  as  a 
rule,  only  when  it  is  in  use;  whereas,  in  tuberculous  disease  of  the 
bone,  pain  is  common  when  the  part  is  not  in  use,  and  it  may 
be  particularly  troublesome  at  night. 

Treatment. — In  disease  of  this,  as  of  other  joints,  functional 
rest  is  indicated.  This  necessitates  fixation  of  the  joint  and 
stilting  of  the  limb,  efficient  traction  being  manifestly  impossible. 
The  foot  should  be  fixed  in  a  light  plaster  Imndage  extending 
extremities  of  the  toes  to  the  upper  third  of  the  leg,  at  a  right 
angle  with  the  leg  and  in  an  attitude  of  slight  inversion,  in  order 
to  guard  against  the  tendency  toward  valgus.  This  deformity 
is  very  common  after  the  cure  of  the  disease,  and  it  often  subjects 
the  patient  to  the  additional  discomfort  of  progressive  flat-foot. 

Reduction  of  Deformity. — If  the  foot  has  become  distorted 
,  before  the  patient  is  brought  for  treatment,  the  plaster  bandage 
may  be  applied  in  the  attitude  of  deformity,  and  at  the  subse- 
quent applications  of  the  dressing,  when  the  muscular  spasm  is 
lessened,  gentle  manipulation  will  gradually  overcome  the  mal- 
position. In  resistant  cases  immediate  reduction  of  the  deformity 
under  anaesthesia  may  be  advisable.  Throughout  the  entire 
course  of  treatment  the  greatest  attention  must  be  paid  to  the 
attitude.  Deformity  is  easily  prevented,  but  is  often  very  diffi- 
cult to  correct,  especially  during  the  later  stages  of  the  disease, 
when  the  tissues  are  infiltrated  and  sensitive,  and  especially  if 
discharging  sinuses   are   present. 

Other  retentive  appliances  may  be  employed,  but  they  are 
inferior  to  a  properly  applied  bandage,  which  holds  its  place  by 
accuracy  of  adjustment,  which  most  eft'ectively  prevents  motion, 
and  which  exercises  a  certain  degree  of  compression  upon  and 
general  support  of  the  swollen  joint.  The  bandage  is  usually 
renewed  at  intervals  of  a  month,  but  it  mav  be  retained  indefi- 


456  ORTHOPEDIC  SURGERY 

nitely  if  it  is  properly  protected  by  a  light  shoe  or  slipper.  The 
Bier  method  of  passive  congestion  may  be  applied  at  the  ankle 
by  means  of  a  bandage  above  the  upper  border  of  the  plaster 
support.  And  the  adhesive  plaster  strapping  may  be  used  beneath 
the  plaster  bandage  if  local  compression  and  more  comprehensive 
support  is  desired. 

The  most  satLsfactorv''  brace  to  serve  as  a  stilt  in  connection 
with  the  local  support  is  the  Thomas  brace,  which  has  been 
described  in  the  section  on  disease  of  the  knee-joint  (Fig.  281). 

^Mien  patients  are  treated  efficiently  the  discomfort  or  incon- 
venience attending  the  disease  is  slight.  As  a  rule,  the  swelling 
of  the  joint  becomes  more  localized  and  finally  an  abscess  appears 
beneath  the  skin.  It  is  then  advisable  to  remove  the  fluid  and 
other  contents  by  means  of  a  simple  incision.  In  most  instances 
a  sinus  persists  for  a  time.  If  the  discharge  is  slight,  the  part 
may  be  dressed  with  ichthyol,  balsam  of  Peru  or  other  applica- 
tion, and  the  whole  enclosed  again  in  the  plaster  bandage;  or,  if 
it  be  more  profuse,  an  opening  may  be  made  and  the  dressing 
applied  outside  the  plaster  bandage.  When  the  stage  of  recovery 
is  reached,  stilting  apparatus  may  be  discarded,  the  patient  being 
allowed  to  bear  the  weight  on  the  foot,  protected  by  the  plaster 
bandage  or  other  support. 

Operative  Treatment. — Early  operation,  especially  of  a  gouging 
character,  should  be  avoided.  An  effective  operation  of  this 
class  often  involves  the  sacrifice  of  bone  that  would  be  spared 
in  the  natural  cure,  and  it  entails  an  irregularity  in  the  growth 
and  causes  deformity  in  after-life  that  may  be  irremediable  (Fig. 
289). 

Similar  operations  in  the  treatment  of  fistulse,  or  abscess,  while 
the  tissues  are  thickened  and  oedematous,  and  while  the  disease 
within  the  joint  is  active,  should  be  postponed  until  the  process 
of  repair  is  more  advanced.  During  the  stage  of  convalescence, 
however,  cure  may  be  hastened  by  the  removal  of  persistent  foci 
of  disease,  or  sequestra  in  the  bone,  or  tuberculous  tracts  in  the 
overlying  soft  parts. 

In  the  adult  or  adolescent,  and  in  exceptional  cases  in  child- 
hood, operative  removal  of  the  disease  may  be  indicated.  If  it 
is  confined  to  the  ankle-joint,  the  removal  of  the  astragalus,  which 
is  usually  the  primary  seat  of  infection,  is  the  operation  of  choice. 

The  op('rati(;n  is  performed  under  the  Esmarch  bandage;  a 
curved  lateral  incision  is  made  passing  beneath  the  external 
malleolus   from    tlic   neighl)r)rli(>0(i    of   the   tendo   Achillis   to   the 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT      457 

anterior  aspect  of  the  joint.  The  lateral  and  capsular  ligaments 
are  divided,  after  which  the  foot  may  be  displaced  inward.  The 
astragalus  is  exposed  and  it  may  be  removed  easily  by  dividing 
the  ligaments  about  its  head  and  its  attachments  to  the  os  calcis. 
All  the  diseased  tissue  in  the  soft  parts  and  in  the  bone  must  be 
removed  thoroughly.  If  the  disease  has  not  extended  to  the 
tarsus,  and  if  it  seems  to  have  been  completely  removed,  the 
wound  may  be  closed,  but  in  most  cases  it  should  be  packed  for 
a  time  with  gauze.  The  after-treatment  is  conducted  as  if  the 
operation  had  not  been  performed,  support  and  fixation  being 
continued  until  it  is  evident  that  the  disease  is  cured. 

Removal  of  the  astragalus  does  not  interfere  to  a  marked  extent 
with  the  function  of  the  foot,  nor  does  it  cause  noticeable  de- 
formity. As  a  primary  operation,  permitting  inspection  and  the 
opportunity  for  thorough  removal  of  all  disease  in  the  neighbor- 
ing parts,  it  should  always  be  performed  in  preference  to  exten- 
sive gouging,  which  is,  as  a  rule,  of  little  avail.  It  may  be  men- 
tioned in  this  connection  that  motion  in  an  anchylosed  joint  may 
be  restored  by  the  removal  of  the  astragalus. 

Prognosis. — Disease  at  the  ankle  is  not  only  less  common,  but 
it  is  less  dangerous  than  that  of  the  larger  joints,  because  it  is 
remote  from  important  structures,  and  because  there  is  less  oppor- 
tunity for  the  burrowing  of  infected  abscesses.  The  duration 
of  the  disease  here  is,  as  a  rule,  shorter  than  at  the  knee  or 
hip,  and  the  final  results  in  childhood  are  almost  always  excel- 
lent. Often  free  motion  is  retained  at  the  ankle,  and  even  if  the 
astragalus  be  fixed  by  disease  the  mobility  in  the  other  joints  of 
the  foot  is  sufficient  to  compensate  very  effectively  for  the  anchy- 
losis. Shortening  of  the  limb  is  of  comparatively  little  conse- 
quence. It  is  not  often  more  than  an  inch,  and  it  may  be  absent. 
The  growth  of  the  foot  is  often  considerably  retarded,  partly  from 
disuse  and  partly  because  of  the  destructive  effect  of  the  disease 
upon  the  tarsal  bones. 

In  the  30  cases  reported  by  Gibney,  treated  expectantly,  in 
which  the  mechanical  treatment  was  far  from  effective,  6  patients 
recovered  with  normal  motion;  11  with  practically  normal  func- 
tion. In  7  there  was  good  motion.  In  6  there  was  anchylosis, 
and  in  3  persistent  valgus.  In  all  the  limb  was  efficient.  In  20 
instances  there  was  no  limp,  and  in  but  1  case  was  it  marked. 
In  no  instance  was  a  crutch,  cane,  or  other  support  used.  The 
average  duration  of  the  disease  was  three  years  and  three  months, 
a  minimum  of  one  year,  a  maximum  of  six  years.     There  were 


458  ORTHOPEDIC  SURGEBY 

2  deaths,  of  which  but  1  was  dependent  upon  the  disease,  septi- 
caemia being  the  cause  assigned,  though  it  is  stated  that  practically 
all  the  bones  of  the  tarsus  were  involved.  In  this  case  amputa- 
tion was  evidently  indicated. 

Tuberculous   Disease   of  the   Tarsus. 

Tuberculous  disease  of  the  joints  of  the  foot,  not  involving  the 
ankle,  is  not  uncommon. 

In  386  of  the  704  cases  reported  by  Hahn,  the  disease  was 
limited  to  the  foot.  In  141  cases  the  mediotarsal  joint  was  in- 
volved; in  51  of  these  the  disease  was  confined  to  this  joint;  in 
46  the  ankle  was  involved;  in  29  the  disease  extended  forward 
to  the  tarsometatarsal  articulation,  and  in  16  the  three  joints 
were  diseased.  In  78  cases  the  tarsometatarsal  joint  was  involved, 
in  33  of  which  the  disease  did  not  extend  beyond  this  articulation. 

Disease  of  Individual  Bones. — In  these  cases  the  distribution 
was  as  follows: 

The  astragalus 170;  disease  confined  to  the  single  bone  in  8 

The  calcaneum 200;         "  "  ''  "  "    87 

The  cuboid 116;         "  "  "  "  "    18 

The  scaphoid 82;         "  "  "  "  "      2 

The  cuneiform  bones     ....        86;         "  ''  "  "  "      8 

in  one-half  of  these  the  disease  was 
of  the  first  metatarsal,  either  alone 


Metatarsal  bones 45;  -,  .  ..  -^u  ^\         i-   • 

'        or  in  connection  with  the  adjoin- 
ing cuneiform  bone  or  phalanx. 

In  a  total  of  1231  cases,  including  these  and  others  reported 
by  Audr)%^  Koenig,^  oMondan,^  Miinch,^  Spengler,^  Vallas,**  Czerny,^ 
and  Dumont,^  the  relative  frequency  of  the  disease  in  the  bones 
of  the  foot  and  ankle  appeared  to  be  as  follows : 

Malleoli      .  .  .        96,     7.7  per  cent.  Scaphoid      .      .      .  110,  8.9  per  cent. 

Astragalus.  .  .  291,  23.6        "  Cuneiform  bones     .  109,  8.8 

Calcaneu.s  .  .  .  339,  25.9       "  Metatarsus.       .       .  110,  8.9 

Cuboid        .  .  .  154,   12.5        "  Phalanges    ...  22,   1.7 

In  disease  at  this  point  limited  to  the  astragalo-navicular  joint 
the  swelling  is  localized  in  front  of  the  ankle  on  the  inner  side 
of  the  foot.  Adchiction  is  restricted,  and  the  foot  is  often  fixed 
in  an  attitude  of  persistent  abduction.  Such  cases  may  be  mis- 
taken for  rigid  weak  foot. 

Disease  of  other  bf)nes  of  the  tarsus  is  indicated  by  the  local 
swelling  and  sensitiveness.     The  disease  sometimes  involves  the 

1  Revue  de  Chir..   1891.  -  ,Scliiiii(h 's  .lahrb.,   1884,   Hd.  cciv. 

•'  DeutHche  Chir.,  ]„  66.  ^  Deutsche  Zeits.  f.  Chir.,  1879,  Bd.  xi. 

li  Ibid.,  1897,  Bd.  xliV.  '  Deutsche  Chir.,  1.,  66. 

'  Volk.  S.  Klin.,  v..  No.  70.  "  Deutsche  Zeitn.  f.  Chir.,  1882,  Bd.  .xvii. 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT      459 

shaft    of   a  metatarsal    bone,   or   one   of   the   phalanges,  causing 
expansion    and    destruction,    "spina    ventosa." 

Treatment  of  Tarsal  Disease. — Disease  of  the  tarsus  shows 
a  marked  tendency  to  extend  from  one  bone  to  another  until  the 
entire  foot  is  involved.  Consequently  if  an  early  diagnosis  is 
made  of  a  distinctly  localized  process  prompt  removal  of  the  dis- 
eased bone  is  indicated;  but  in  most  instances  the  disease  is  too 
extensive  to  permit  of  its  radical  removal.  In  such  cases  opera- 
tive intervention  is  contraindicated,  and  the  treatment  by  protec- 
tion similar  to  that  employed  in  disease  of  the  ankle,  is  indicated. 
In  childhood  the  prognosis  is  very  good  even  when  the  disease  is 
extensive,  but  in  adult  life  amputation  of  the  foot  may  be  advis- 
able because  of  the  time  required  to  assure  a  natural  cure  and 
because  an  artifical  leg  provides  a  better  support  than  a  stiff  and 
sensitive  extremity.  Amputation  is  almost  always  indicated, 
if  there  is  co-existent  disease  of  the  lungs. 

Sprain   of   the   Ankle. 

The  ankle  is,  from  its  position,  especially  liable  to  injuiy;  in 
fact,  the  term  "sprain"  is  popularly  associated  with  this  joint. 

A  sprain  is  most  often  caused  by  an  unguardefl  movement,  by 
which  the  foot  is  turned  suddenly  inward  or  outward,  with  suffi- 
cient force  to  injure  the  synovial  membrane,  to  rupture  some  of 
the  fibres  of  the  muscles,  to  strain  tendons  and  tendon  sheaths, 
and  even  to  rupture  ligaments.  If  the  foot  is  twisted  inward 
the  injury  is  most  marked  on  the  outer  side  of  the  joint;  if  out- 
ward, on  the  inner  side  of  the  ankle.  In  the  slighter  degrees  of 
sprain  the  injury  may  be  confined  to  the  tissues  about  the  joint, 
but  in  most  instances  there  is  effusion  within  the  capsule,  even 
hemorrhage  when  injury  has  been  severe. 

Symptoms. — The  immediate  symptoms  of  sprain  are  pain, 
often  intense,  of  a  throbbing  character,  swelling,  heat,  and  in 
many  instances  discoloration  of  the  surrounding  parts,  even 
extending  over  the  leg  and  foot. 

Treatment. — If  an  opportimity  for  immediate  treatment  is 
offered,  the  swelling  and  the  effusion  of  blood  may  be  restrained 
by  the  application  of  elastic  stockinette  bandages  from  the  toes 
to  the  knee.  As  much  compression  is  exercised  as  the  comfort 
of  the  patient  will  allow,  and  the  bandage  should  be  made  suffi- 
ciently thick  to  prevent  painful  motion.  If  the  injury  has  been 
severe  and  if  the  part  is  very  sensitive  to  motion  or  jar,  the  joint. 


460 


ORTHOPEDIC  SURGERY 


ha^■ing  been  protected  xNith  cotton,  may  be  fixed  in  a  light  plaster 
bandage.  This  may  be  cut  dowii  the  front  to  allow  for  daily 
massage  of  the  foot,  ankle,  and  leg,  which  is  of  great  service  in 
hastening  the  absorption  of  the  effusion. 

The  use  of  hot  air,  hot  and  cold  water,  and  static  electricity, 
and  the  like  .are  of  service  also  in  relieving  the  discomfort  and 
more  especially  in  stimulating  the  circulation,  upon  which  repair 
depends. 

By  far  the  most  effective  treatment  during  the  stage  of  recovery 
and  as  an  immediate  application  for  sprains  of  slighter  degree,  is 
the  adhesive  plaster  strapping  which  has  been  popularized  by 
Gibney.  His  method  is  as  follows:  Strips  of  adhesive  plaster 
about  three-quarters  of  an  inch  in  width  and  from  nine  to  eighteen 

Fig.  290 


A  method  of  applying  adhesive  plaster  strapping  for  sprain  of  the  ankle. 

inches  in  length  are  prepared.  A  long  strip  is  placed  with  its 
centre  beneath  the  heel,  and  the  two  ends  are  carried  upward 
over  the  malleoli,  to  a  point  at  the  junction  of  the  middle  and 
lower  thirds  of  the  leg.  A  second  strip  is  placed  at  the  posterior 
extremity  of  the  heel,  and  the  two  ends  are  carried  forward  some- 
what beyond  the  tarsometatarsal  junction  on  either  side.  Another 
strip  is  then  placed  by  the  side  of  the  first,  and  the  fourth  by  the 
side  of  the  second,  until  the  entire  ankle  is  smoothly  covered,  except 
for  a  space  about  two  inches  in  width  directly  on  the  front  of  the 
ankle.  One  takes  particular  care  to  make  the  plaster  fit  well 
about  the  malleoli  and  reinforces  it  at  the  points  of  greatest  sen- 
sitiveness. A  light  bandage  is  then  applied  and  the  patient  is  en- 
couraged to  use  the  focjt  in  walking.     The  plaster  may  be  applied 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT      461 

in  a  variety  of  ways;  a  satisfactory  method  is  as  follows,  after  the 
preliminary  massage  for  the  purpose  of  reducing  the  swelling: 
One  end  of  a  strip  of  adhesive  plaster  about  three  feet  long 
and  three  inches  wide  is  applied  to  the  lateral  aspect  of  the  leg 
just  below  the  knee-joint;  it  is  carried  down  the  side  of  the  leg 
over  the  malleolus,  beneath  the  heel  and  arch,  and  up  the  other 
side  to  a  point  opposite  the  beginning  where  it  is  fixed  by  a  cir- 
cular band  about  the  calf.  If  the  sprain  is  of  the  outer  side  of 
the  ankle,  sufficient  tension  is  made  upon  the  outer  half  of  the 
plaster  to  hold  the  foot  slightly  abducted.  If,  as  is  more  common 
the  sprain  is  of  the  inner  side,  the  inner  half  is  drawn  firmly  be- 
neath the  arch,  carrying  the  foot  toward  inversion  so  that  all  strain 
may  be  removed  from  the  sensitive  part.     This  band  of  plaster 

Fig.   291 


The  stockinette  bandage. 

is  reinforced  by  one  or  more  so  that  the  lateral  aspect  of  the  ankle 
is  completely  covered.  And  in  addition  the  entire  ankle  is  then 
enclosed  with  narrow,  overlapping  strips  which  cover  all  the  tissues 
well  beyond  the  sensitive  area.  The  foot  and  leg  are  then  bandaged 
to  assure  the  adhesion  of  the  plaster.  \Mien  the  joint  is  firmly 
held  by  the  supporting  plaster  the  patient  can,  as  a  rule,  walk 
M'ith  comfort;  and  he  is  encouraged  to  do  so,  for  functional  use, 
provided  it  does  not  cause  additional  injury,  is  the  most  efiective 
stimulant  of  the  circulation;  thus  the  patient  applying,  as  it  were, 
an  automatic  massage,  cures  himself. 

As  the  swelling  subsides  the  plaster  strapping  wrinkles,  and  it 
must  be  renewed,  about  three  applications  being  required,  as  a 
rule,  the  last  of  which  is  allowed  to  remain  until  all  of  the  symp- 
toms have  disappeared,     ^^igorous  massage  before  applying  the 


462  ORTHOPEDIC  SURGERY 

new  dressing  is  of  service  in  hastening  the  cure.  It  is  perhaps 
needless  to  state  that  a  prehminarv  shaving  of  the  part  will  add 
somewhat  to  the  comfort  of  the  patient. 

Chronic   Sprain. 

A  chronic  sprain  may  be  the  result  of  an  inefficiently  treated 
acute  injury,  in  which  an  improper  attitude  originally  assumed 
to  spare  the  sensitive  part  finally  becomes  habitual.  In  other 
instances  persistent  disability  may  be  the  result  of  fixation  of  the 
joint  for  too  long  a  time  in  splints.  Such  disuse  causes  atrophy 
of  the  muscles  and  of  the  bones  as  well  (see  Atrophy,  page  244), 
while  the  effused  material  within  and  without  the  joint  remains 
because  of  the  imperfect  circulation.  The  same  disability  may 
follow  simple  disuse  of  the  injured  part.  It  is  more  often  observed 
in  nervous  individuals  who  exaggerate  the  importance  of  the  injury 
and  the  discomfort  that  it  causes.  In  such  cases  the  limb  may 
be  discolored  by  venous  congestion,  the  foot  may  be  oedematous 
and  the  movements  may  be  limited  by  adhesions  or  by  muscular 
adaptation  to  the  habitual  attitude. 

In  other  instances  the  original  injury  may  have  caused  a  slight 
subluxation  of  the  astragalus,  sufficient  to  throw  the  foot  into  an 
attitude  of  abduction,  in  which  it  has  become  fixed  by  the  second- 
ary changes  in  the  muscles  and  ligaments.  In  some  cases  of  this 
class  the  original  sprain  was  at  the  mediotarsal  or  at  the  sub- 
astragaloid  joint,  and  its  effect  has  been  traumatic  weak  foot.  It 
may  be  stated,  also,  that  many  of  the  so-called  sprains  of  the  ankle 
are  simply  injuries  of  a  weak  foot,  a  disability  to  which  the  treat- 
ment should  be  directed.     (See  the  Weak  Foot.) 

Treatment. — treatment  must  be  conducted  with  the  aim  of  re- 
storing the  normal  range  of  motion  and  so  supporting  the  part 
that  normal  functional'use  may  be  permitted.  If  adhesions  have 
formed  and  if  the  foot  is  persistently  held  in  an  abnormal  attitude, 
forcible  manipulation  under  anaesthesia  may  be  required  as  a 
preliminary  treatment,  followed  by  fixation  for  a  time  in  a  plaster 
banrlage,  in  the  attitude  directly  opposed  to  that  which  has  been 
ha};itual.  In  this  class  of  cases  the  habitual  attitude  is  usually 
one  of  equinovalgus;  the  foot  should  be  fixed  for  a  time,  therefore, 
in  a  plaster  bandage  in  a  position  of  extreme  varus,  at  a  right  angle 
with  the  leg,  and  upon  it  the  patient  is  encouraged  to  bear  his 
weight  both  in  standing  and  walking.  When  all  discomfort  has 
disappeared,  a  sup[)ort,  usually  a  light  leg  brace  to  prevent  lateral 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT         463 

motion,  and  if  the  arch  is  depressed  a  foot  plate  also,  should  be 
worn  for  a  time.  The  most  effective  curative  aojent  is  functional 
use,  but  massage,  hot  air,  passive  manipulation,  and  exercises 
are   valuable   accessories. 

Injuries  of  this  class  are  very  amenable  to  treatment,  con- 
ducted with  the  aim  of  restoring  normal  function,  if  proper  sup- 
port is  provided  during  the  period  of  pain  and  weakness. 

Tenosynovitis. 

The  sheaths  of  the  tendons  about  the  ankle-joint,  if  involved 
in  a  sprain  of  the  ankle,  may  cause  persistent  interference  with 
function ;  or  strain  of  a  tendon  and  of  its  sheath  may  cause  symp- 
toms of  disability  when  the  joint  is  uninjured.  The  symptoms  of 
acute  tenosynovitis  are  discomfort  on  motion  of  the  affected  tendon, 
and  this  motion  may  be  accompanied  by  a  peculiar  creaking  which 
is  apparent  on  palpation.  In  many  instances  there  is  slight  local 
swelling  and  sensitiveness  to  pressure  about  the  affected  part,  and 
the  movements  of  the  foot  that  call  the  muscle  into  action  are  painful. 

The  arrangement  of  the  tendon  sheaths  should  be  borne  in 
mind.  At  the  ankle-joint  all  the  tendons  are  provided  with  sheaths ; 
on  the  front  of  the  foot  are  three — the  sheath  of  the  tibialis  anticus, 
which  extends  from  a  point  about  two  inches  above  the  extremity 
of  the  malleolus  to  the  navicular  bone  (Fig.  292);  that  of  the 
extensor  longus  hallucis,  from  the  annular  ligament  to  the  head 
of  the  first  metatarsal,  and  the  common  sheath  for  the  extensor 
communis  digitorum,  extending  from  a  point  about  half  an  inch 
above  the  malleoli  to  about  one  inch  below  the  annular  ligament. 
Behind  the  internal  malleolus  are  the  common  sheaths  of  the  tibialis 
posticus  and  flexor  longus  digitorum,  beginning  about  an  inch 
above  the  extremity  of  the  malleolus  and  extending  to  the  astragalo- 
navicular  junction  and  that  of  the  flexor  longus  hallucis  of 
about  the  same  extent  (Fig.  293).  Behind  the  outer  malleolus 
is  the  sheath  of  the  two  peronei,  beginning  one  inch  above  the  mal- 
leolus, dividing  into  two  portions  for  the  two  tendons  and  ending- 
just  behind  the  tuberosity  of  the  fifth  metatarsal  bone  (Fig.  294). 

Treatment. — Simple  traumatic  tenosynovitis  should  be  treated 
by  rest  and  by  compression.  An  effective  treatment  is  strapping 
with  adhesive  plaster,  so  applied  as  to  prevent  the  movements  of 
the  foot  that  cause  discomfort.  In  more  painful  and  persistent 
cases  the  use  of  a  plaster  bandage  to  assure  absolute  rest  may  be 
necessary.     Cautery  applied  over  the  affected  part  is  of  service. 


464 


ORTHOPEDIC  SURGERY 


Chronic  tenosynovitis  may  follow  injury  or  it  may  be  the  result 
of  gonorrhoea  or  other  infectious  disease.  In  chronic  cases  when 
the  palliative  treatment  is  ineffective,  thorough  removal  of  the 
affected  sheath  is  indicated.     (See  Achillobursitis.) 

Ttberculous   Tenosynovitis. — A  persistent  and   increasing 
swelling  of  a  tendon  sheath  always  suggests  tuberculous  disease. 


Fig.    292 


Fig.   293 


The  internal  annular  ligament  of  the  ankle  and  the  arti- 
ficially distended  synovial  membranes  of  the  tendons 
which  it  confines.     (Testut,  from  Gerrish's  Anatomy.) 

Fig.   294 


The  anterior  annular  li«arnent  of 
the  ankle  and  the  synovial  mem- 
branes of  the  tendons  beneath  it 
artificially  distended.  (Testut,  from 
Gerrish's  Analomy.) 


The  external  annular  ligament  of  the  ankle  and  the  arti- 
ficially distended  synovial  membranes  of  the  tendons 
which  it  confines.     (Testut,  from  Gerrish's  Anatomy.') 


DISEASES  AND  INJURIES  OF  THE  ANKLE-JOINT       4(35 

In  such  instances  the  sac  Ls  thickened  and  often  contains  the 
so-called  rice  bodies.  Prompt  and  complete  removal  of  the  dis- 
eased sheath  is  indicated,  and  by  this  means  a  permanent  cure 
may  be  attained  in  most  instances. 

Swelling  about  the  Ankles.— Occasionally  either  in  combina- 
tion with  weak  feet  or  independent  of  it,  one  finds  a  distinct  swelling 
about  the  ankles  most  marked  in  front  of  the  external  malleoli. 
This  is  apparently  an  extension  from  the  joint  made  up  of  synovial 
and  fatty  tissue.  In  most  instances  the  patients  are  fat  and  the 
apparent  cause  is  overweight. 

Fio.   295 


'^I'he  patients  usually  complain  of  weakness  and  discomfort. 
The  treatment  aside  from  reduction  of  weight,  and  support  for  the 
weakened  arch,  is  massage,  strapping  and  bandaging.  The  oper- 
ative removal  of  the  swollen  tissue  is  indicated  in  obstinate  cases. 

Other  Affections  of  the  Ankle-joint. 
The  ankle-joint  may  be  the  seat  of  an  infectious  arthritis;  it 
may  be  mvolved  in  an  osteomyelitis  of  the  tibia.  It  may  be 
one  of  the  joints  affected  in  chronic  rheumatism  or  rheumatoid 
arthritis,  and  occasionally  Charcot's  disease  may  appear  in  this 
situation.  The  principles  of  the  treatment  of  these  affections 
have  been  indicated  elsewhere. 

30 


CHAPTER   XII 


DISEASES    AND    INJURIES    OF    THE    ARTICULATIONS    OF    THE 
UPPER  EXTREMITY. 

Tuberculous   Disease   of  the   Shoulder-joint. 

Disease  at  the  shoulder  is  very  uncommon  in  childhood.  In 
a  total  of  453  cases  of  tuberculous  disease  treated  at  the  Vander- 
bilt  clinic  210  were  cases  of  Pott's  disease.  In  6  of  the  remain- 
ing 243  cases  the  disease  was  of  the  shoulder-joint  (2.5  per  cent.). 

In  1883  consecutive  cases  of  joint  disease — Pott's  disease  being 
excluded — treated  in  the  out-patient  department  of  the  Hospital 
for  Ruptured  and  Crippled  in  a  period  of  five  years,  the  shoulder- 

FiG.   296 


^^::' 


■r 


Section  of  the  shoulder-joint  at  the  age  of  eight  years.  (Schuchardt.)  Ossification 
appears  in  the  epiphysis  of  the  head  of  the  humerus  at  the  end  of  the  first  year;  a  second 
point  appears  in  the  greater  tuberosity  during  the  second  year.  These  unite  between  the 
fourth  and  sixth  years.    Ossification  is  complete  between  the  eighteenth  and  twentieth  years. 

joint  was  involved  in  38  instances  (2  per  cent.).  In  1900  cases 
of  joint  disease  treated  at  Billroth's  clinic,  the  shoulder  was  in- 
volved in  14,  or  less  than  1  per  cent. 

Pathology. — The  disease  usually  begins  in  the  head  of  the 
hiinicnis.  In  32  observations  on  adults  recorded  by  Mondan  and 
Aruiry/  the  primary  disease  was  of  the  h(>a(l  of  the  humerus  in 
23  cases,  of  the  humerus  and  scapula  in  4,  of  the  scapula  alone 
in  1,  and  in  3  instances  it  appeared  to  be  primarily  synovial. 

'   Hevue  de  Chir.,   1892. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    467 

In  the  majority  of  cases  abscess  fornxs  and  comes  to  the  surface 
near  the  insertion  of  the  deltoid  muscle.  In  advanced  cases  the 
tissues  of  the  axilla  and  of  the  adjoining  thorax  may  be  infiltrated 
and  perforated  by  numerous  sinuses.  Not  infrequently  the  dis- 
ease is  of  the  form  called  caries  sicca,  in  which  there  is  no  swell- 
ing, but  progressive  destruction  of  the  head  of  the  humerus  by 
granulation  tissue.  This  form  is  characterized  by  extreme  mus- 
cular atrophy  and  by  practical  anchylosis. 

Statistics. 

Age  at  Incipiency  of  Disease  at  the  Shoulder-joint  in  Sixty-two 
Consecutive  Cases  Treated  at  the  Hospital  for  Ruptured  and 
Crippled. 

1  year  or  less 1         13  years  old 3 

2  years  old 6         15  "  2 

3  "  1  18  "  3 

4  "  3  19  "  5 

5  •'  3  20  "  4 

6  "  1  23  "  1 

7  "  3  26  "  2 

8  "  4  27  "  1 

9  "  6  34  "  1 

10  "  1         48  "  1 

11  "  5         56  "  1 


12 


Total 62 

Males,  38;  females,  24;  right,  35;  left,  27. 


Townsend^  made  a  detailed  report  on  21  cases  treated  at  the 
Hospital  for  Ruptured  and  Crippled  during  the  years  1S89  to 
1893.  Ten  of  these  were  less  than  ten  years  of  age;  7  were 
between  ten  and  twenty,  and  4  were  more  than  twenty.  The 
youngest  patient  was  three  and  a  half  and  the  age  of  the  oldest 
was  thirty-five  years.  In  5  cases  the  disease  was  secondary  to 
disease  of  other  parts;  in  1  case  to  Pott's  disease;  in  2  to  hip 
disease,  and  in  2  to  disease  of  the  knee-joint. 

Symptoms. — The  history  of  the  case  will  show  the  persistent 
and  progressive  character  of  the  disability,  but  the  symptoms 
characteristic  of  tuberculous  disease  are  far  less  marked  at  the 
shoulder  than  at  other  joints.  This  is  explained  by  the  fact  that 
the  upper  extremity  is  not  subjected  to  weight  bearing  and  be- 
cause the  mobility  of  the  scapula  upon  the  thorax  lessens  the 
injury  caused  by  unguarded  movements  of  the  arm.  This  double 
joint  at  the  shoulder  masks  the  interference  with  the  function  of 
the  joint,  and  the  strain  caused  by  overuse  may  be  lessened  by 

^  Transactions    American'Orthopedic  Association,  vol.  vii. 


468 


ORTHOPEDIC  SURGERY 


the  unconscious  restraint  that  the  patient  can  exercise  upon 
motion  at  this  joint.  In  fact,  even  when  absohite  anchylosis  is 
present  the  patient  may  think  that  motion  is  but  moderately 
restricted. 

The  symptoms  of  the  disease  may  be  classified  as  fain,  sensi- 
tiveness,   restrietion   of  motion,    atrophy. 

There  is  usually  a  dull  ache  about  the  joint,  with  occasional 
neuralgic  pain  referred  to  the  elbow  and  arm.     The  discomfort 


Fig.    297 


Tuburcul(jus  disease  of  the  sliouliler-joint. 


is  increased  by  movements  that  pass  beyond  the  limits  allowed 
by  the  mobility  of  the  scapula,  especially  on  attempting  to  rotate 
the  humerus,  as  in  clothing  one's  self  or  brushing  the  hair.  The 
joint  is  sensitive  to  pressure;  thus  tlu;  patient  finds  that  he  cannot 


lie  on  th(!  affected  side  at  night. 


The  noniinl  ijiiigc  of  rn(;tion  between  adduction  and  abduction  is 
abf>ut  90  degrees,  and  between  flexion  and  extension  somewhat  less. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    469 

On  examination  the  limitation  of  motion  caused  by  muscailar 
spasm  will  be  evident  if  the  scapula  is  fixed,  so  that  movement 
of  the  joint  can  be  tested. 

Pressure  upon  the  head  of  the  humerus  usually  causes  pain, 
and  in  many  instances  local  heat  and  swelling  are  present.  The 
atrophy  of  the  shoulder  muscles  is  often  extreme  and  that  of  the 
other  muscles  of  the  limb  is  well  marked. 

As  has  been  stated,  abscess  is  a  common  accompaniment  of  the 
disease,  and  in  such  cases  the  tissues  about  the  joint  are  swollen 
and  infiltrated.  In  other  instances  there  is  progressive  destruc- 
tion of  the  head  of  the  humerus  without  abscess  formation  (caries 
sicca).  In  cases  of  this  type  the  flattening  of  the  shoulder  may 
be  so  extreme  as  to  be  mistaken  for  subcoracoid  dislocation. 

Treatment. — The  treatment  of  the  disease  here  as  elsewhere 
is  rest.  To  assure  absolute  functional  rest  the  wrist  should  be 
attached  to  the  neck  by  a  sling,  the  elbow  being  flexed  to  an 
acute  angle;  the  arm  is  then  fixed  to  the  thorax  by  a  bandage. 
Local  rest  and  compression  may  be  still  further  assured  by  strips 
of  adhesive  plaster  applied  over  the  shoulder  and  extending  to 
the  back  and  chest;  or  a  shoulder-cap  of  leather  or  plaster  may 
be  employed.  This  method  of  fixing  the  bare  arm  to  the  chest  is 
the  only  one  that  assures  continuous  rest,  as  changes  of  the  clothing 
necessitate  movement  of  the  joint.  During  the  acute  phases  of 
the  disease  the  arm  may  be  supported  in  the  attitude  of  extreme 
abduction  by  means  of  a  triangular  splint  or  pad.  This  position 
is  often  that  of  greatest  comfort  to  the  patient.  Direct  traction 
is  not  often  employed,  as  support  of  the  pendent  limb  is  usually 
preferred  by  the  patient. 

Operative  Treatment. — If  the  focus  of  disease  seems  to  be  local- 
ized, an  exploratory  operation  for  its  early  removal  may  be  in- 
dicated. Excision  of  the  joint  in  the  adult  cases,  or  arthrectomy 
in  younger  subjects,  may  be  advisable  when  suppuration  is  per- 
sistent or  when  for  other  reasons  it  may  seem  best  to  attempt  to 
remove  the  diseased  area. 

Prognosis. — The  duration  of  the  disease  appears  to  be  from 
two  to  five  years.  The  death-rate  is  higlier  than  in  tlisease  of 
the  joints  of  the  lower  extremity,  because  a  larger  proportion  of 
the  patients  are  adults,  and  in  this  class  tuberculosis  of  the  lungs 
is  not  an  infrequent  complication. 

It  is  impossible  to  speak  positively  of  the  results  of  the  con- 
servative treatment  of  disease  of  the  shoulder.  The  disease  is 
uncommon,  and  protection   is   almost  never  applied    in   the   in- 


470  ORTHOPEDIC  SURGEBY 

cipient  stage,  nor  efficiently  and  persistently  employed  to  the 
end.  The  ordinary  result  is,  therefore,  anchylosis,  usually  of 
the  fibrous  rather  than  of  the  bony  variety. 

If  the  disease  appears  in  early  life  the  growth  of  the  limb  may 
be  seriously  interfered  with;  an  inch  or  more  of  shortening  from 
this  cause  is  not  uncommon. 

Tuberculous  Disease   of  the  Elbow-joint. 

Tuberculous  disease  of  the  elbow-jomt  is  the  fourth  in  order 
of  frequency,  preceding  the  shoulder  and  the  wrist.  Of  1883 
consecutive  cases  of  joint  disease  treated  at  the  Hospital  for  Rup- 
tured and  Crippled  56  were  of  the  elbow. 

Pathology. — The  primary  disease  is  in  most  instances  osteal 
as  in  92.8  per  cent,  of  the  cases  investigated  by  Scheimpflug,  44 
in  nimiber.^  The  original  focus  of  infection  is  somewhat  more 
often  of  the  ulna  than  of  the  humerus.  Of  the  ulna  the  olecranon 
process,  and  of  the  humerus  the  external  condyle,  appear  to  be 
the  points  of  election.  Disease. of  the  head  of  the  radius  is  com- 
paratively infrequent.  In  119  cases  reported  by  Oilier  the  olec- 
ranon was  involved  in  73,  the  humerus  in  33,  and  the  radius  in 
12  instances.^  And  in  the  cases  investigated  by  Knmmer,^  and 
Middledorpt,^  the  ulna  was  more  often  the  seat  of  the  primary 
disease  than  was  the  humerus,  but  in  81  cases  treated  in  Koenig's 
clinic  the  primary  disease  was  of  the  humerus  in  43,  of  the  olecranon 
in  30,  and  of  the  radius  in  2  instances.^ 

Statistics. 

Age  at  Incipiency  of  Disease  at  the  Elbow-joint  in  Fifty-nine 
Consecutive  Cases  Treated  at  the  Hospital  for  Ruptured  and 
Crippled. 

1  year  or  less 2         13  years  old 3 

2  years  old 5  14  "  2 


3 

.      8 

31 

15 
17 
19 
21 
23 
25 
29 

,  riKht, 

Total        .      . 
27;  left,  32. 

4 

."} 

.      5 

0 

.      .      4 

7 

.      8 

8 

1 

2 

9 

.      .      2 

.      .      .      1 

10 

U 

.      .      1 

.      .      .    59 

Malew 

28; 

females, 

1   Festschrift    fur   Billroth,    1892. 

-  Karewski,   Chir.  Krank.  des  Kindersalters,  p.  208. 

'^  Deutsche  Zeits.  f.  Chir.,  Bd.  xxvii. 

■•  Archiv  f.  klin.  Chir.,   Bd.  xxxiii. 

'    Koenin,   Lehrbuch    .Spec.    Chir.,    Berlin,    1900. 


DISEASES  OF  ARTICULAT102^S  OF  UPPER  EXTREMITY    471 

Symptoms. — The  symptoms  are  those  of  a  chronic,  persistent, 
destructive  disease.  Pain,  local  sensitiveness  and  swelling,  siijj- 
ness,  deformity,  atrophy. 

The  pain  is  usually  localized  at  the  elbow.  It  is  increased  by 
sudden  movements,  and  as  the  bones  are  so  superficial  there  is 
usually  local  sensitiveness  to  pressure,  most  marked  over  the  seat 
of  the  disease.  In  the  early  stage  the  swelling  is  slight,  and  it 
is  of  the  peculiar  elastic  character  due  to  thickening  of  the  tissue 

Fig.   298 


^B. '-  -.-^^  ----^'fl^^l 

n  1 

Tuliei'culous  disease  of  the  ellxiw-joint 


rather  than  to  effusion  within  the  capsule,  but  as  the  disease 
progresses  the  joint  assumes  the  peculiar  spindle  shape  charac- 
teristic of  white  swelling.  The  degree  of  elevation  of  the  local 
temperature  depends  upon  the  activity  of  the  disease.  The  most 
important  physical  sign  is  the  restriction  of  motion  due  to  the 
characteristic  muscular  spasm  which  becomes  evident  when  the 
limit  of  painless  motion  is  passed.  The  limitation  of  extension 
and  flexion  gradually  increases,  and  finally  the  limb  becomes 
fixed  in  an  attitude  midwav  between  flexion  and  extension,  with 


472 


ORTHOPEDIC  SURGERY 


the  forearm  in  an  attitude  between  pronation  and  supination. 
This  is  the  characteristic  deformity  of  the  disease. 

Atrophy  of  the  muscles  of  the  arm  and  forearm  is  present, 
corresponding  to  the  intensity  and  duration  of  the  disease  and  to 
the  functional  disability  of  the  joint. 

Treatment.— The  treatment  here  as  elsewhere  consists  essen- 
tially in  placing  the  joint  at  rest  in  the  attitude  at  which  anchy- 
losis or  limitation  of  motion  will  least  inconvenience  the  patient, 


Fig.    299 


Tuberculous  disease  of  tlie  elbow-joint;  the  stage  of  recovery. 

and  at  tiie  ell)OW-joint  this  is  practically  at  right  angular  flexion 
(Fig.  299). 

In  the  treatment  of  young  children  the  wrist  may  be  attached 
closely  to  the  neck  Ijy  means  of  a  sliug,  with  the  elbow  at  an  acute 
angle  (the  Thomas  method)  within  the  clothing.  Or  a  light 
plaster  bandage  may  be  used  to  fix  tlie  joint,  the  wrist  being  sup- 
ported \)y  a  sling.  'J'his  enables  the  patient  to  dress  himself 
without  moving  the  i)art  and  it  protects  the  joint  from  injury. 
Other  forms  of  splints  may  he  employed,  but  the  ])laster  bandage 
answers   every   purf)ose.     It  should,  of  course,  extend   from   the 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    473 

axilla  to  the  hand,  and  in  sensitive  cases  it  may  include  the  hand 
also. 

Reduction  of  Deformity. — In  many  instances  the  arm  is  fixed  in 
the  semi-extended  attitude  when  the  patient  is  brought  for  treat- 
ment. In  this  class  of  cases  a  simple  and  effective  means  of 
reducing  deformity  is  that  suggested  by  Thomas.  When  it  is 
impossible  to  l)ring  the  wrist  to  the  neck,  one  bends  the  neck 
toward  the  wrist  and  attaches  the  two  by  a  bandage  that  the 
patient  is  unable  to  remove.  From  this  uncomfortable  attitude  the 
patient  can  free  himself  only  by  drawing  the  arm  toward  the  neck 
and  thus  reducing  the  deformity.  At  the  next  visit  the  same 
procedure  is  repeated,  until  finally  the  elbow  is  flexed  to  the  required 
degree.  A  permanent  sling  may  be  constructed  of  a  leather 
wrist-band  and  a  tube  of  leather  to  pass  about  the  neck,  through 
which  the  bandage  may  be  drawn;  thus  the  pressure  on  the  wrist 
and  neck  may  be  lessened.  In  the  very  resistant  cases  reduction 
of  deformity  under  anaesthesia  may  be  required,  but  this  is  not 
often  necessary. 

Prognosis. — If  the  case  is  treated  at  an  early  stage  the  prog- 
nosis in  childhood  is  good.  The  duration  of  treatment  may  be 
estimated  at  two  years  or  more,  and  retention  of  a  fair  range  of 
motion  may  be  expected.  Anchylosis  in  the  right-angled  position 
does  not,  however,  seriously  inconvenience  the  patient,  provided 
the  cure  is  absolute.  The  loss  of  growth  is  usually  less  than 
when  the  upper  epiphysis  of  the  humerus  has  been  destroyed,  the 
final  disproportion  depending,  of  course,  upon  the  age  of  the 
patient  and  upon  the  degree  of  function  that  is  preservetl. 

Operative  Treatment. — In  some  instances  it  is  possible  to  re- 
move small  foci  of  disease  from  the  humerus,  or  from  the  ulna, 
before  the  joint  is  involved.  The  position  of  the  disease  may  be 
indicated  by  sensitiveness  or  swelling,  and  in  older  subjects  a 
Roentgen   picture  may  demonstrate   its   position   accurately. 

Excision  of  the  Elbow. — Excision  is  often  advisable  in  adolescent 
or  adult  life,  because  by  this  procedure,  in  most  instances,  thc^ 
disease  may  be  cured  in  a  definite  time  and  because  a  m()val)ie 
joint  may  be  assured. 

Oschman  has  recently  investigated  the  final  results  of  the  opera- 
tion performed  on  this  class  at  Kocher's^  clinic  at  Berne,  1872- 
1897.  In  40  of  45  cases  the  operation  was  performetl  for  tubercu- 
lous disease.  There  were  no  deaths  referable  to  the  operation. 
Of  the  entire  num])er  of  cases  15  were  dead,  but  11  of  these  survived 

1  Archiv  f.  klin.  Chir.,  Bd.  Lv.,  H.  2 


474 


OBTHOPEDIC  SURGERY 


the  operation  for  from  five  to  twenty-years.  Eight  of  the  deaths 
were  due  to  tuberculosis,  2  to  other  causes,  and  in  5  the  cause 
of  death  was  unknown.  In  96  per  cent,  of  the  cases  the  local 
disease  was  cured.  In  68  per  cent,  of  the  cases  the  patients  were 
able  to  use  the  limb  at  hard  labor,  and  in  the  others  it  was  efficient 
for  light  work.  .  In  6  cases  there  was  subluxation  or  luxation ;  in  5 
the  joint  was  not  firm.  In  59  per  cent,  the  motions  were  practically 
normal.     In  11  per  cent,  the  joint  was  anchylosed. 


Tuberculous  disease  of  the  wrist  and  knee-joints,  showing  the  characteristic  deformities 
in  neglected  cases  of  a  severe  type. 

Tuberculous    Disease    of   the   Wrist-joint. 

Disease  of  the  wrist-joint  is  very  uncommon  in  childhood.  In 
a  total  of  3105  cases  of  tuberculous  disease  treated  in  the  out- 
patient department  of  the  Hospital  for  Ruptured  and  Crippled 
during  a  period  of  five  years,  98  were  of  the  upper  extremity,  and 
in  but  4  of  these  was  the  wrist-joint  involved.  Of  43  cases  in 
which  the  joint  was  resected  by  Oilier,  the  youngest  patient  was 
thirteen  years  oi  age. 

Of  990  cases  of  disease  of  the  joints  in  childhood,  reported  by 
Karewski,  the  wrist  was  involved  in  31.^ 


{;hir.  Krarik.  des  KindcM'saltcrs,  Berlin,  1894. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    475 

Disease  of  the  wrist  in  older  subjects  is  less  infrequent,  although 
at  all  ages  it  is  rare  as  compared  with  disease  in  other  joints. 
Tuberculous  disease  of  the  metacarpus  and  phalanges  (spina 
ventosa)  is,  however,  far  more  common. 

Age  at  Incipiency  of  Disease  at  the  Wrist-joint  in  Eighteen 
Consecutive  Cases  Treated  at  the  Hospital  for  Ruptured  and 
Crippled. 

2  years  old 1  19  years  old 2 

6  "  1  20  "          2 

9  "  1  25  "          2 

12  "  2  2G  "          2 

14  "  1  27  "          1 

16  "  2  — 

17  "  1                                  Total 18 

Males,  11;  females,  7;  right,  12;  left,  6. 

Symptoms. — The  symptoms  of  tuberculous  disease  of  the  wrist 
are,  as  in  other  situations,  'pain,  local  swelling,  and  sensitiveness, 
limitation  of  motion,  caused  by  muscular  spasm,  and  atrophy.  In 
advanced  cases  the  hand  is  usually  flexed  somewhat  upon  the  arm. 

Treatment. — The  treatment  of  this,  as  of  other  joints,  is  func- 
tional rest,  with  support  in  the  attitude  in  which  anchylosis  or 
limitation  of  motion  will  cause  the  least  inconvenience.  A  light 
plaster  bandage  extending  from  the  elbow  to  the  tips  of  the  fingers, 
applied  over  a  flannel  bandage  drawn  as  tight  as  the  comfort  of  the 
patient  will  permit,  is  a  satisfactory  support;  or  a  leather  splint 
or  other  form  of  appliance  may  be  used.  The  hand  should  be 
held  in  an  attitude  of  moderate  dorsal  flexion,  which  will  permit 
the  flexor  muscles  to  close  the  fingers  easily  if  the  wrist  becomes 
fixed  by  the  disease.  If  flexion  deformity  is  present  it  should 
be  corrected  by  degrees,  with  each  application  of  the  bandage, 
until  the  desired  attitude  is  attained  (Fig.  302).  The  flannel 
bandage  exercises  a  certain  amount  of  compression  upon  the  wrist , 
which  seems  to  be  of  benefit,  and  in  certain  instances  this  com- 
pression and  fixation  may  be  still  further  increased  by  the  appli- 
cation of  adhesive  plaster.  Bier's  treatment  by  passive  congestion 
maybe  applied,  and  according  to  reports  it  is  especially  efficacious 
at  this  joint.  When  the  disease  of  the  joint  is  quiescent,  or  in  the 
stage  of  recovery,  the  bandage  or  splint  may  be  shortened  to  allow 
the  patient  to  use  the  fingers. 

Prognosis. — The  prognosis  as  regards  function  in  cases  treated 
promptly  in  childhood  should  be  good.  In  the  adult  cases  wrist- 
joint  disease  seems  to  be  very  often  complicated  by  disease  of  the 
lungs;  thus  the  prognosis  as  to  life  is  often  bad.     In  this  class 


476 


ORTHOPEDIC  SURGERY 


of  cases  early  excision  is  usually  recommended,  with  amputation 
as  a  final  resort. 

Spina   Ventosa. 

Central  disease  of  the  long  bones  of  the  foot  and  hand  is  the 
most  common  form  of  diaphyseal  tuberculosis.     While  the  cortical 

Fig.   301 


in 

R 

3 

»' W-iife. 

1 

^H 

1-   "^ 

'  .^    JHMj 

l^^^^l 

P(^^ 

Tuberculou.-i  disease  of  the  right  wrist-joint,  showing  the  swelling  and  the  limitation  of 

motion. 


Fig.   302 


Treatment  of    tuberculosis  of  tiie  wrist-joint   by   itlustcr-of-l'aris,  siiowinM;    tlie  i)roper 

attitude. 

substance  is  destrf)y('d   froiri   within  it  is  often   replaced  in  part 
by  a  formation  of  jM-riosteal  l>one  from  witliout,  wliicli  in  turn  may 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    477 

be  destroyed  by  the  advancing  disease.     In  the  early  cases  the 
affected  bone  is  enlarged,  spindle-shaped,  and  is  somewhat  sen- 

FiG.   303 


Tuberculous  disease  of  the  carpus. 
Fig.   304 


Tuberculous  disease  of  the  left  wrist-joint.  The  irregularity  and  the  diminished  size 
of  the  carpal  bones  indicate  the  extent  of  the  destructive  process.  The  patient,  the  mother 
of  the  child  (Figs.  10  and  11)  with  Pott's  disease,  died  within  a  year,  of  tuberculosis  of 
the  lungs. 

sitive  to  pressure.  At  this  stage  repair  may  take  place  with  but 
little  ultimate  change  from  the  normal,  but  in  many  instances 
the  bone  is  perforated  and  in  part  destroyed,  the  neighboring 
joint  is  involved,  and  the  finger  becomes  stunted  and  distorted. 


478  ORTHOJ'EDIC  SURGERY 

In  159  cases  tabulated  by  Karewski/  the  metacarpal  bones 
were  diseased  in  65  instances;  the  phalanges  in  57;  the  meta- 
tarsal bones  in  29;  the  phalanges  of  the  toes  in  8.  In  a  number 
of  instances  several  of  the  bones  and  larger  joints  were. involved 
also  (159  cases  in  135  patients). 

The  disease  is  more  common  in  the  early  years  of  life,  84  of 
the  135  patients  being  four  years  of  age  or  less,  38  of  these  being 
less  than  two. 

Spina  ventosa  of  the  phalanges  may  be  treated  by  rest  and 
compression,  and  both  splinting  and  compression  may  be  assured 
by  adhesive  plaster  strapping.  If  the  joint  is  involved  amputa- 
tion of  the  finger  may  be  indicated,  because  of  the  distortion,  and 
loss  of  growth  that  may  be  expected.  Tuberculous  disease, 
limited  to  a  single  bone  of  the  carpus  or  metacarpus,  may  be 
treated  by  operative  removal  of  the  disease. 

Periarthritis    of  the    Shoulder. 

Under  the  title  of  scapulohumeral  periarthritis,  Duplay^  in 
1872  described  a  painful  affection  of  the  shoulder  induced  by 
injury,  dependent  upon  an  inflammation  of  the  bursa  lying 
between  the  deltoid  and  supraspinatus  and  infraspinatus  muscles 
and  the  coracoacromial  ligament.  But  under  this  title  are  now 
included  a  number  of  affections  that  cause  similar  symptoms  in 
which  it  would  appear  that  the  interior  of  the  joint  is  not  involved. 

Symptoms. — In  a  typical  case  of  so-called  periarthritis  the 
patient  complains  of  a  dull  pain  about  the  joint  and  sensitiveness 
to  pressure  just  below  the  acromion  process  or  over  the  bicipital 
groove.  The  pain  is  increased  by  motion,  particularly  by  abduc- 
tion or  by  rotation  of  the  arm.  In  mild  cases  only  extensive  motion 
causes  pain,  but  in  most  instances  there  is  a  constant  sensation 
of  fliscomfort  which  is  increased  to  acute  pain  by  sudden  move- 
ments or  jars.  The  part  becomes  sensitive  to  pressure,  so  that 
tlie  patient  avoids  lying  on  the  shoulder  at  night.  In  certain 
instances  the  pain  may  radiate  down  the  arm,  and  there  may  be 
weakness  and  numbness  of  the  fingers.  Gradually  the  passive 
movements  of  the  joint  are  diminished  in  range,  and  atrophy  of 
the   shoulder   muscles    app(;ars. 

Tliese  symptoms  usually  pass  as  rheumatism,  but  there  is  no 
fever,  no  involvement  of  other  joints,  no  swelling,  and,  as  a  rule, 

'  C;hir.  Krank.  des  Kindersalters,  Berlin,  1894. 
'^  Archiv.   gdndrale  do  mild.,   Paris,   1872. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    479 

no  general  sensitiveness  to  pressure,  as  is  usual  when  the  synovial 
membrane  of  the  joint  is  affected.  In  certain  instances  the 
symptoms  follow  injury,  or  exposure  to  cold,  or  they  appear 
without  apparent  cause.  In  one  class  of  cases  the  symptoms  may 
be  due  to  an  inflammation  of  the  subdeltoid  bursa,  as  in  the  cases 
originally  described  l)y  Duplay;  in  others  to  a  tenosynovitis  of 
the  biceps  tendon.  This  is  suggested  by  local  sensitiveness  at 
the  bicipital  groove,  and  by  the  creaking  sensation  at  this  point 
when  the  muscle  is  in  use.  Or  the  symptoms  may  be  due  to 
neuritis  affecting  the  circumflex  nerves,  as  suggested  by  Amidon.^ 
It  is  probable  also  that  the  nerves  in  the  neighborhood  of  the 
joint  may  be  secondarily  implicated  in  an  inflammation  of  bursse, 
or  directly  injured  by  the  original  traumatism,  if  such  preceded 
the  symptoms.  It  is  also  possible  that  the  bursitis  may  have 
been  a  sequel  of  gonorrhoea  or  of  other  infectious  disease. 

Treatment. — During  the  acute  and  painful  stage  the  part  should 
be  kept  at  rest.  Cautery  may  be  applied  and  the  joint  should  be 
enclosed  in  adhesive  plaster  strapping,  and  if  the  weight  of  the  limb 
causes  discomfort  it  should  be  supported.  In  certain  instances 
tension  on  the  sensitive  part  may  be  relaxed  by  supporting 
the  arm  in  an  attitude  of  abduction.  Wlien  the  acute  symptoms 
have  subsided  passive  movements,  massage,  and  static  electricity 
are  of  service.  Voluntary  exercises  should  be  employed  when 
they  no  longer  aggravate  the  symptoms.  In  the  cases  of  long 
standing  in  which  motion  is  very  much  restricted,  apparently 
by  adhesions  without  the  joint,  passive  movements  under  anaes- 
thesia to  the  extremes  of  the  normal  range  are  usually  of  benefit. 
In  such  cases  it  may  be  well  to  support  the  limb  for  a  time  in  the 
abducted  attitude  to  prevent  the  formation  of  the  adhesions. 
Afterward  passive  motion,  massage,  and  exercises  must  be  em- 
ployed to  prevent  the  return  of  the  restriction.  If  these  cases  are 
treated  carefully  in  the  early  stage,  recovery  is  usually  rapid,  but 
if  neglected  the  symptoms  may  persist  indefinitely. 

Chronic   Bursitis. 

Chronic  bursitis  at  tiie  shoulder-joint  is  comparativ(>ly  infre- 
quent. The  bursffi  most  often  involved  are  the  coracoid,  the 
subscapular,  and  the  deltoid.  Of  these  the  last  is  the  most  often 
affected.     Sixteen  cases   have   been  reported   by   Blauvelt,-   and 

^  American  Medico-Surgical  Bulletin,  March  21.   1896. 
-  Beitriige  zur  klin.  Chir.,  Bd.  xxii. 


480  ORTHOPEDIC  SURGERY. 

three  others  by  Ehrhardt/  The  enlarged  bursa  forms  a  fluctuat- 
ing swelHng  most  noticeable  on  the  anterior  and  outer  aspect 
of  the  shoulder,  the  symptoms  being  discomfort,  weakness,  and 
limitation  of  motion  of  the  arm.  The  disease  is  usually  tuber- 
culous in  character,  and  it  should  be  treated  by  complete  removal 
of  the  sac  if  possible. 

Sprain   of   the   Wrist. 

This  is  a  very  common  accident.  The  most  effective  treatment 
is  the  adhesive  plaster  strapping  applied  about  the  metacarpus, 
wrist,  and  lower  half  of  the  forearm.  If  the  pain  on  motion  is 
severe  sufficient  plaster  is  applied  to  splint  the  part  and  to  limit 
movement  to  the  point  of  comfort.  If  the  injury  is  of  a  slighter 
grade  the  compression  and  support  of  a  single  layer  of  plaster  is 
usually  sufficient.  This  dressing  prevents  strain,  and  yet  it  allows 
a  certain  degree  of  functional  use,  which  is  the  most  effective 
means  of  restoring  a  joint  to  its  normal  condition  by  hastening 
the  absorption  of  the  effused  material  within  and  without  the 
injured  part. 

Chronic  Sprain. — Persistent  weakness  and  stiffness  may  follow 
treatment  of  a  sprain  by  splints  or  when  for  any  reason  disuse  of 
function  has  been  long  continued.  In  many  instances,  however, 
the  sprain  was  in  reality  a  fracture  or  displacement.  All  chronic 
sprains,  therefore,  should  be  examined  by  means  of  the  x-ray  in 
order  that  the  presence  or  absence  of  more  extensive  injury  may 
be  determined. 

The  treatment  is  similar  to  that  of  the  acute  sprain:  protection 
from  injury,  and  functional  use  to  the  extent  of  which  the  part  is 
capable.  With  this,  passive  congestion,  massage,  hot  air,  and 
electricity  or  other  form  of  local  stimulation  may  be  employed 
with  advantage.  The  same  treatment  is  indicated  when  the  joint 
is  stiff  and  painful  as  the  result  of  rheumatism  or  other  inflamma- 
i\()\\,  pnnidcd  the  stage  (^f  recovery  has  been  reached. 

Acute  Tenosynovitis. 

Tenosynovitis  is  connnon  at  the  wrist-joint.  It  is  usually 
induced  by  strain  or  overuse  of  a  muscle  or  muscular  group. 

Movements  of  tfie  muscles  that  are  involved  cause  discomfort, 
and  there  is  usually  local  sensitiveness  and  a  creaking  sensation 

'  ,\rchiv  f.  klin.  Chir.,  ]^d.  Ix. 


DISEASES  OF  ARTICULATIONS  OF  UPPER  EXTREMITY    481 

on  palpation  over  the  affected  tendon  sheath.  The  adhesive 
plaster  strapping,  so  applied  as  to  exert  compression  and  to 
prevent  the  motion  that  causes  discomfort,  is  the  most  effective 
treatment. 

Chronic  tenosynovitis,  causing  progressive  enlargement  of  a 
tendon  sheath,  with  accompanying  symptoms  of  weakness  and 
discomfort,  is  usually  tuberculous  in  character.  In  such  cases 
the  diseased  part  should  be  promptly  removed.  If  the  disease  is 
of  long  standing,  extending  into  the  palm  of  the  liand  it  may 
be  advisable  to  simply  evacuate  the  contents,  including  the  rice 
bodies,  through  an  incision.  An  astringent  solution  may  be 
injected,  and  after  its  removal  the  incision  may  be  closed.  Pres- 
sure is  then  applied,  with  the  aim  of  securing  partial  adhesions 
of  the  apposed  surfaces. 


31 


CHAPTER    XIII. 

DEFORMITIES  OF  THE  UPPER  EXTREMITY. 

Congenital   Dislocation   of   the    Shoulder. 

This  may  occur  in  two  forms,  one  in  which  there  is  actual 
misplacement  before  birth,  and  the  other  in  which  a  dislocation 
is  caused  by  violence  at  birth.  In  either  case  the  displacement 
is  almost  always  backward  upon  the  dorsum  of  the  scapula  (sub- 
spinous). Thus  the  arm  is  abducted  and  rotated  inward,  and 
the  head  of  the  displaced  bone  may  be  felt  in  its  abnormal  position. 
Cases  of  congenital  displacement  in  other  directions  are  recorded, 
but  these  are  so  unusual  as  to  be  of  little  practical  importance/ 

True  primary  displacement  of  either  variety  is  uncommon. 
Many  of  the  reported  cases  were  apparently  subluxations  secondary 
to  the  relaxation  of  the  capsule  of  the  joint  and  to  the  muscular 
atrophy  caused  by  anterior  poliomyelitis,  or  more  often  to  the 
habitual  malposition  due  to  obstetrical  paralysis  (Fig.  306). 
According  to  Porter,^  twenty-nine  cases  are  recorded  in  literature, 
in  at  least  half  of  which  the  diagnosis  is  doubtful.  It  is,  of  course 
apparent  that  both  displacement  and  paralysis  may  be  coincident 
and  caused  by  injury  at  birth. 

Obstetrical   Paralysis. 

Partial  or  complete  paralysis  of  the  muscles  of  the  arm  may 
be  a  result  of  difficult  or  protracted  labor.  It  may  be  induced  by 
direct  pressure  on  the  brachial  plexus,  but  most  often  it  is  caused 
by  traction  on  the  body  or  the  head,  and  by  violent  twists  of  the 
neck  during  delivery.  In  rare  instances  the  paralysis  may  be 
bilateral.  In  some  instances  the  nerve  roots  may  be  torn  apart, 
in  others  the  injury  may  })e  principally  to  the  sheath  causing 
hemorrhage,  and  in  the  process  of  repair  scar  tissue  which  presses 
upon  the  nerve  ek'iucnts.  '^J^lic  muscl(>s  most  often  paralyzed  are 
those  sii[jj)lic(l  ])i'iiK'ipally  by  the  fiflli  and  sixth  cervical  roots 
of  the  j)l('xus — ti)c  deltoid,  the  biceps,  and  the  suj)inat()rs  of  the 

'  Scudder,  American  Journal  of  the  Medical  Sciences,  February,  189S. 
2  TranHactionH  American  Orthopedic  Association,  1900,  vol.  xiii. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY 


483 


forearm.  Thus  in  most  instances  the  arm  hangs  in  an  attitude  of 
slight  abduction  and  exaggerated  pronation  (Fig.  300).  If  the 
attitude  is  allowed  to  persist  and  if  the  paralysis  is  permanent, 
the  head  of  the  humerus,  rotated  backward  beneath  the  atrophied 
deltoid  muscle  and  finally  fixed  in  the  abnormal  attitude  by 
accommodative  changes  in  the  capsule  and  surrounding  parts, 
simulates  very  closely  in  later  years  the  true  congenital  dislocation 
of  the  shoulder  (Fig.   307). 


Congenital  dii^local  ion  ol 


nncrus,  illiHt  lar  inc;  the  characteristic  attitude. 


Whether  cases  reported  as  congenital  displacement  of  the  humerus 
are  secondary  to  paralysis  or  not,  it  is  evident  that  all  cases  of 
obstetrical  paralysis  should  be  carefully  examined  with  regard 
to  a  complicating  dislocation,  and  that  the  secondary  deformity 
induced  by  paralysis  should  be  prevented. 

Treatment. — During  the  first  month  after  birtli  the  shoulder 
of  the  paralyzed  arm  is  often  somewhat  swollen,  and  motion  may 


484 


ORTHOPEDIC  SURGERY 


Fig.   306 


cause  pain.  In  such  cases  rest  is  indicated.  The  arm  should  be 
placed  against  the  side,  and  the  hand,  with  the  fingers  extended, 
should  be  supported  on  the  chest  beneath  the  clothing.  When 
the  primary  sensitiveness  has  subsided,  each  of  the  joints  of  the 
extremity  should  be  moved  systematically  to  the  limit  of  the  normal 
range  of  motion  several  times  in  a  day.  Particular  care  should  be 
exercised  in  supinating  the  forearm  and  extending  the  wrist  and 
fingers,  if  they  are  involved  in  the  paralysis.     The  muscles  should 

be  massaged,  and  the  arm  should 
be  supported  by  a  sling,  or  other- 
wise, in  proper  position.  Recov- 
ery may  be  complete,  although 
it  is  often  delayed  for  many 
months.  As  a  rule,  traces  of  the 
injury  are  evident  in  atrophy  of 
certain  muscles,  particularly  of 
the  deltoid,  and  a  certain  weak- 
ness of  the  arm  persists,  even 
though  no  actual  paralysis  re- 
mains. 

In  many  instances  recovery  is 
but  partial,  the  arm  is  weak,  cer- 
tain muscles  are  paralyzed,  and 
there  is  much  restriction  of  move- 
ment at  the  shoulder.  The  growth 
of  the  member  is  retarded,  and 
as  has  been  mentioned,  the  at- 
titude is  that  characteristic  of 
posterior  dislocation.  Not  in- 
frequently, although  the  actual 
paralysis  is  slight,  the  disability 
is  extreme  because  of  the  dis- 
placement. The  essential  in 
treatment,  therefore,  is  to  replace  the  head  of  the  humerus  in  the 
proper  position.  This  applies  to  the  congenital  as  well  as  to  the 
acquired  disjibih'ty. 

Reduction  of  Deformity. — The  principles  of  the  treatment  of 
the  displaced  hiiiMcnis  are  to  reduce  the  deformity,  to  fix  the  part 
for  a  time  sufncicnt  to  prevent  relapse,  to  restore  function  as  far 
as  may  be  by  systematic  passive  motion,  and  by  exercise. 

The  child  having  been  anaesthetized,  is  brought  to  the  edge 
of  the  tal)le.     The  shonldcr  is  grasped  firmly  with  one  hand  in 


The  characteristic  attitude   of  ob.stetrical 
paralysis  in  infancy. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY  485 

order  to  restrain  the  movements  of  the  scapula,  and  witli  the  other 
the  arm  is  drawn  upward  and  backward  over  the  fulcrum  of 
the  thumb,  which  lies  behind  the  joint.  This,  the  so-called  pump- 
handle  movement,  alternately  relaxing  and  stretching  the  contracted 
parts,  is  carried  out  over  and  over  again  with  slowly  increasing 
force,  the  aim  being  to  force  the  head  of  the  bone  forward,  and 
thus  to  overcome  the  resistance  of  the  anterior  part  of  the  capsule. 

Fig.   307 


The  deformity  of  obstetrical  paralysis  in  adolescence. 

Wlien  this  has  been  accomplished,  there  is  a  distinct  depression 
behind,  and  the  head  of  the  humerus  projects  in  front,  at  a  point 
below  its  proper  position. 

One  then  attempts  to  overcome  the  abduction  and  to  force  the  head 
upward  by  changing  the  grasp  on  the  scapula  and  using  the  thumb 
in  the  axilla  as  a  fulcrum.  When  the  arm  can  be  carried  across 
the  chest  to  the  normal  degree  of  adduction,  the  final,  and  often  most 


486  ORTHOPEDIC  SURGERY 

difficult,  part  of  the  process,  namely,  to  stretch  the  tissues  suffi- 
ciently to  permit  the  proper  degree  of  outward  rotation,  is  under- 
taken. This  is  best  accomplished  by  flexing  the  forearm  and  using 
this  to  exert  leverage  on  the  humerus,  care  being  taken,  of  course, 
to  avoid  the  danger  of  fracture,  ^^^len  the  head  of  the  bone  has 
been  replaced,  it  will  often  be  noted  that  the  tension  on  the  anterior 
tissues  causes  flexion  of  the  forearm;  this  must  be  overcome  in  the 
same  manner,  and,  finally,  the  limitation  to  complete  supination. 
The  extremity  is  then  fixed  in  the  over-corrected  attitude  by  means 
of  a  plaster  bandage  which  includes  the  thorax.  That  is,  the 
arm  is  drawn  backward  so  that  the  head  of  the  humerus  is  made 
prominent  anteriorly,  the  forearm  is  flexed  and  turned  outward  to 
the  frontal  plane,  while  the  hand  is  placed  in  extreme  supination, 
the  arm  lying  against  the  lateral  thoracic  wall. 

In  the  very  resistant  cases  it  is  impracticable  to  complete  the 
operation  at  one  sitting.  When,  therefore,  as  much  force  has  been 
exercised  as  seems  wise,  a  plaster  bandage  is  applied,  and  after 
an  interval  of  two  weeks  the  further  correction  is  undertaken. 
This,  however,  is  not  often  necessary.  In  the  treatment  of  older 
subjects  the  forcible  manipulation  may  be  preceded  or  supple- 
mented by  division  of  resistant  parts. 

As  has  been  stated  when  the  head  of  the  bone  is  forced  forward 
a  distinct  depression  and  evident  relaxation  of  the  tissues  is  noted 
on  the  posterior  aspect  of  the  joint.  The  object  of  the  fixation  is 
to  allow  the  contraction  of  the  posterior  wall  of  the  capsule  and 
the  obliteration  of  the  old  articulation,  consequently,  the  part 
must  be  fixed  for  a  period  of  at  least  three  months.  When  the 
plaster  bandage  is  removed,  the  after-treatment  is  of  great  impor- 
tance. This  consists  of  daily  passive  forcible  movements  to  the 
extreme  limits  in  the  directions  formerly  restricted;  namely,  outward 
rotation,  backward  extension,  and  eventually  abduction  of  the 
humerus  and  supination  and  extension  of  the  forearm.  For  in  all 
these  cases  there  is  a  strong  tendency  to  a  return  in  some  degree 
to  the  original  posture.  When  motion  has  become  fairly  free, 
the  disabled  member  must  be  regularly  exercised  and  re-educated 
in  functional  use.  Under  this  treatment  the  weakened  and  almost 
completely  atrophied  muscles  usually  gain  surprisingly  in  power 
and  ability,  and  the  longer  it  is  continued  the  better  will  be  the 
final  result.  If  the  deltoid  muscle  is  completely  paralyzed,  one 
cannot  expect  independent  irKjvement  at  the  shoulder,  and  the  aim 
should  be  to  gain  fibrous  ankylosis  in  the  attitude  of  outward 
rotation  in  order  to  [)ermit  supination  of  the  forearm. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY  487 

Repair  of  Obstetrical  Injury  to  the  Brachial  Plexus. 

It  is  evident  that  if  repair  of  tlie  ruptured  or  otlierwi.se  injured 
cords  of  the  brachial  plexus  does  not  take  place,  recovery  is  impos- 
sible. If  then  the  paralysis  persists,  direct  operative  intervention 
may  be  indicated  in  selected  cases. 

Kennedy^  has  operated  on  a  number  of  cases  for  this  purpose, 
in  one  instance  as  early  as  two  months  after  birth. 

His   method   is   as   follows: 

An  incision  from  above  downward  is  made  along  the  posterior 
border  of  the  sternomastoid  to  the  junction  of  the  middle  and  outer 
thirds  of  the  clavicle.  The  deep  fascia  is  divided,  the  omohyoid 
is  depressed,  and  the  scaleni  muscles  are  exposed  between  the 
anterior  and  middle  of  which  passes  the  plexus  with  the  sub- 
clavian artery  below;  the  uppermost  cords  of  the  plexus  are  usually 
involved.  The  scar  tissue  is  cut  away  and  the  freshened  surfaces 
are  then  united.  The  wound  is  closed,  the  head  is  inclined 
toward  the  shoulder,  and  a  plaster  support  is  applied.  Several 
encouraging  results  of  this  operation  have  been  reported. 

If  the  deformity  is  of  long  standing,  operations  on  the  injured 
nerves  of  somewhat  doubtful  utility  at  best  can  have  no  influence 
on  the  disability  unless  distortions  and  contractions  have  been 
overcome  in  the  manner  already  described. 

Recurrent  Dislocation  of  the  Shoulder. 

Recurrent  dislocation  of  the  shoulder  is  in  mcst  instances  a 
sequel  of  traumatic  dislocation.  The  cause  of  the  instability  is 
usually  laxity  of  the  capsular  ligament  and  weakness  of  the  sup- 
porting muscles,  the  result,  it  may  be,  of  too  early  use  of  the  arm 
after  the  accident.  In  rare  instances  greater  derangement  of  the 
joint  caused  by  fracture  of  one  or  other  of  the  articulating  sur- 
faces, rupture  or  displacement  of  ligaments  or  muscles,  or  per- 
manent paralysis  of  the  deltoid  muscle  may  be  present. 

The  displacement,  which  may  be  partial  or  complete,  recurs  at 
intervals  and  is  a  very  serious  disability. 

Treatment. — If  the  patient  is  seen  immediately  after  a  displace- 
ment and  if  the  dislocation  has  recurred  but  a  few  times  and  at 
long  intervals,  it  may  l)e  inferred  tliat  the  disability  is  the  result 
of  simple  laxity  of  tiie  capsule  and  of  muscular  weakness.     In 

1  Brit.  Med.  .Tour.,  190.3,  p.  298. 


488 


ORTHOPEDIC  SURGERY 


such  cases  a  period  of  fixation  followed  by  massage  and  exer- 
cise of  the  atrophied  muscles  may  result  in  cure.  The  patient 
should  be  carefully  questioned  as  to  the  particular  movements  of 
the  arm  that  are  likely  to  cause  the  displacement,  which  is,  as  a 
rule,  forward  beneath  the  coracoid  process.  Most  often  elevation 
and  abduction  seem  to  be  the  predisposing  movements  that  should 
be  restrained.  A  simple  and  often  an  effective  means  of  treat- 
ment is  the  application  of  a  shoulder-cap  of  canvas  that  fits  closely 


Fig.   308 


Bilateral  congenital  pronation  of  the  forearms. 

about  the  shoulder  and  uj)per  arm.  This  is  held  in  place  by  bands 
crossing  the  body  and  l)iickled  beneath  the  other  arm;  from  the 
lower  border  of  the  cap  oik;  or  mon;  bands  pass  downward  and 
are  attached  with  the  l)rac('S  to  tiu;  trousers,  so  that  elevation  of 
the  arm  is  rcsl rained,  before  the  point  of  insta})ility  is  reached. 
Operative  Treatment.  If  these-  milder  measures  are  ineffective, 
an  operation  to  redncc  the  si/,(;  of  the  lax  capsule  may  be  per- 
formed.    'l'h(;  arm   being  slightly  ab(hict(>d,  an  incision  is  made 


DEFORMITIES  OF  THE  UPPER  EXTREMITY  489 

from  the  coracoid  process  downward  and  outward  along  the  line 
of  the  cephalic  vein  to  a  point  below  the  upper  border  of  tlie  tendin- 
ous insertion  of  the  pectoralis  major.  The  deltoid  and  the  pec- 
toralis  major  are  separated,  exposing  in  the'  upper  border  of  the 
wound  the  coracobrachialis,  and  in  the  lower  angle  the  upper  part 
of  the  insertion  of  the  pectoralis  major  muscles.  The  upper 
three-fourths  of  this  insertion  is  divided  in  order  to  expose  the 
head  and  neck  of  the  bone.  The  humerus  is  then  rotated  outward 
and  a  portion  of  the  insertion  of  the  subscapularis  muscle, 
stretched  over  the  head  of  the  humerus,  is  divided.  The  capsule 
is  thus  laid  bare,  and  a  sufficient  section  is  removed  to  overcome 
the  laxity.     The  wound  is  then  closed. 

Similar  operations  in  which  the  lax  capsule  was  overlapped 
and  sutured  without  opening  it  have  been  performed,  by  Ricard 
in  1892  and  by  Steinthal  in  1895.' 

Congenital   Deformities   of   the    Elbow. 

Congenital  displacement  of  the  ulna  is  one  of  the  rarest  of 
deformities.  The  displacement  is  usually  incomplete,  and  it  is 
associated  with  laxity  of  the  ligaments. 

Congenital  displacement  of  the  radius  is  much  more  common, 
53  cases  having  been  reported." 

In  many  instances  the  head  of  the  radius  is  displaced  backward ; 
thus  the  forearm  is  pronated  and  extension  is  usually  limited. 
In  some  cases  a  certain  range  of  pronation  and  supination  is 
present  but  in  others  the  two  bones  are  joined  by  bony  growth 
(Fig.  308).  Excision  of  the  head  of  the  radius,  separation  of  the 
bones,  fixation  for  a  time  in  the  attitude  of  supination  followed  by 
passive  motion,  and  exercises  would  be  indicated  in  operative 
treatment. 

Cubitus   Valgus,   Cubitus   Varus. 

Cubitus  valgus,  in  which  the  forearm  is  abducted  at  the  elbow, 
and  cubitus  varus,  in  which  it  is  inclined  in  the  other  direction, 
are  occasionally  seen  as  congenital  deformities.  They  are,  in 
most  instances,  associated  with  laxity  of  the  ligaments. 

Similar  deformities  are  not  uncommon  during  the  progressive 
stage  of  rhachitis,  but  they  usually  disappear  after  the  erect 
attitude  is  assumed,  when  the  arms  are  relieved  of  the  strain  of 
supporting  the  body  in  the  sitting  posture. 

'  Burrell  and  Lovett,  American  Journal  of  the  Medical  Sciences,  August,  1897. 
^  Blodgett,  Amer.  Journ.  Orth.  Surg.,  January,  1906. 


490  ORTHOPEDIC  SURGEBY 

The  forearm  forms  an  angle  with  the  upper  arm,  opening 
outward  when  the  Hmb  is  extended  at  about  173  degrees  in  males 
and  167  degrees  in  females/  This  is  sometimes  called  the  "carry- 
ing" angle,  because  the  hantl  is  held  at  some  distance  from  the 
body  while,  the  arm  is  in  contact  with  the  trunk,  ^^^lat  may  be 
called  normal  cubitus  valgus  is  common  among  women,  and  in 
certain  instances  it  may  be  exaggerated  to  deformity.  Acquired 
cubitus  varus  is  usually  the  result  of  direct  injury.  Both  de- 
formities may  be  treated  by  osteotomy  of  the  humerus  just  above 
the  articulation  after  the  method  used  to  correct  similar  de- 
formity at  the  knee.  If  in  addition  to  the  lateral  deformity  motion 
is  restricted  by  displaced  fragments  of  bone  or  by  exuberent 
callus  it  is  advisable  to  open  the  jomt  for  the  purpose  of  removing 
the  obstructions.  After  operation  for  the  correction  of  lateral 
deformity  the  arm  should  be  fixed  by  a  plaster  bandage  which 
should  include  the  hand  in  full  extension. 

Fig.   309 


"SixjntaneoUb  subluxation  of  the  wrist." 

Subluxation  of  the  Wrist. 

A  peculiar  displacement  of  the  hand  forward  and  usually  toward 
the  radial  side,  described  by  Madelung"  as  "spontaneous  subluxa- 
ti(m,"  is  .sometimes  .seen  in  young  subjects  whose  occupation  may 
require  constant  use  of  the  flexors  of  the  hand  and  fingers.  In 
these  ca.ses  the  lower  extremity  of  the  ulnar  is  displaced  toward 
the  dorsum  of  the  hand;  there  is  abnormal  separation  of  the  two 
bones  of  the  forearm  from  one  another  at  the  wrist,  and  in  many 
in.stances  the  lower  extremity  of  th(;  radius  is  bent  forward.  As 
a  con.sequerice  the  wrist  is  enlarged,  the  ligaments  are  relaxed, 

'  Potter,  .Journal  of  Anatomy  and  I'liy.siolfJKy,  vol.  xxix.  p.  488. 
*  Archiv  f.  klin.  Cliir.,  JJd.  xxiii. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY  491 

and  dorsal  flexion  of  tlie  Iiand  is  restricted.  The  symptoms, 
aside  from  the  deformity,  are  weakness  and  sensations  of  discom- 
fort about  the  dorsum  of  the  wrist. 

Etiology. — The  predisposing  causes  of  the  affection  are,  appar- 
ently, relaxation  of  the  ligaments,  and,  possibly,  slight  pre-existing 
rhachitic  deformity  of  the  same  character.  The  exciting  causes 
are  occupation  or  injury.  The  slight  forward  bending  of  the 
lower  extremity  of  the  radius  is  due,  apparently,  to  irregularity 
in  growth  at  the  epiphyseal  junction. 

Treatment. — The  treatment  is  rest,  massage,  forcible  manipu- 
lation in  the  direction  of  extension,  and  a  support  of  leatlicr  or 
other  material  to  hold  the  hand  in  tlie  extended  position.  In 
more  extreme  cases  the  deformity  of  the  radius  may  l)e  overcome 
by  osteotomy. 

Congenital  [Deformities    at   the   Wrist. 

Simple  congenital  dislocation  at  the  wrist  is  extremely  rare. 
Displacement  of  the  wrist  and  hand  is  usually  associated  with 
defective  development  of  the  bones  of  the  arm,  and  the  deformity 
is  usually  classed  as  club-hand. 

Club-hand. 

Congenital  distortions  of  the  hand  may  be  divided  into  four 
primary  varieties,  according  to  the  direction  in  which  the  hand  is 
turned,  viz.  : 

1.  Forward  or  palmar. 

2.  Backward  or  dorsal. 

3.  Lateral  to  the  radial  side — radial. 

4.  Lateral  to  the  ulnar  side — ulnar. 

Lateral  and  anteroposterior  distortions  occur  also  in  combina- 
tion. 

Etiology. — There  are  two  distinct  varieties  of  club-hand : 

1.  Li  which  there  is  simple  distortion  caused  apparently  by 
abnormal  restraint  and  pressure  in  iitcro.  In  certain  cases  of 
this  class  there  may  be  limited  motion  at  both  the  shoulder  and 
elbow-joints  and  defective  muscular  development,  apparently 
dependent  upon  long-continued   fixation. 

2.  In  which  the  deformity  is  associated  with  defective  develop- 
ment of  the  radius  or  ulna  and  often  with  congenital  abuormali- 
ties  of  other  parts. 


492 


ORTHOPEDIC  SURGERY 


In  the  palmar  and  dorsal  distortions  the  bones  of  the  arm  are 
usually  normal.  The  lateral  deviations  of  the  hand  are  often 
complicated  by  defective  formation  of  the  radius  or  ulna,  and  as 
in  talipes  due  to  absence  of  the  tibia  or  fibula  the  hand  may  be 
malformed  also. 

Deficient  formation  of  the  radius  with  corresponding  distortion 
is  the  most  common.  Of  this  114  cases  are  recorded.  In  56  cases 
it  was  stated  that  the  deformity  was  unilateral,  in  46  bilateral. 
In  44  cases  the  radius  was  absent;  in  12  cases  a  part  was  present; 
60  per  cent,  of  the  patients  were  males. ^ 

Fig.   310 


Club-hands  and  club-feet. 

The  rao'st  important  form  of  club-hand  is,  then,  that  due  to 
absence  or  to  defective  formation  of  the  radius.  As  in  talipes 
valgus  due  to  absence  of  the  fibula,  the  tibia  is  short  and  often 
bent  sharply  forward,  so  in  this  form  of  club-hand  the  ulna  is 
usually  short  and  bent  inward.  The  hand  may  be  perfect  in 
formation,  but,  as  a  rule,  the  thumb  is  absent  or  rudimentary,  and 
other  adjoining  bones,  together  with  the  corresponding  ligaments 
and  muscles,  may  be  absent  also  (Fig.  311). 

The  hand  occupies  practically  a  right-angled  relation  to  the 


'   Antonelli,   Zeita.  f.  orth.  Chir.,  1005,  Bd.  xiv. 


DEFORMITIES  OF   THE  UPPER  EXTREMITY 


493 


ulna,  and  as  this  bone  is  usually  bent  inward  as  well,  the  direction 
of  the  hand  is  often  reversed  and  is  parallel  to  the  forearm.  As 
a  rule,  the  hand  is  also  somewhat  bent  forward,  so  that  the  defor- 
mity might  be  described  as  radiopalmar  (Fig.  312). 

Treatment. — In  those  forms  of  club-hand  in  which  the  struc- 
ture is  normal  the  deformity  may  be  overcome,  as  a  rule,  by  manipu- 
lation, and  support  by  the  plaster  bandage  or  otherwise,  as  de- 
scribed in  the  treatment  of  talipes.  Massage  and  muscle  training 
are  required  in  the  after-treatment.     If  the  deformity  is  complicated 


Congenital  absence  of  radius  and  the  bones  of  the  thumb.     (Weigel.) 

by  defective  muscular  development  and  limited  joint  motion 
massage  and  passive  manipulation  may  be  required  for  years. 
Complete  recovery  is  unusual. 

In  slighter  cases  of  radial  club-hand,  due  to  defective  develop- 
ment, it  may  be  possible  by  manipulation  antl  tenotomy  to  replace 
the  hand  in  its  normal  position,  but  this  is  unusual.  As  a  rule, 
an  operation  on  the  ulna  will  be  necessary,  together  with  divi- 
sion of  the  contracted  tissues.  Sayre^  removed  a  portion  of  the 
carpus  and  implanted  the  head  of  the  ulna  at  the  point  of  resec- 
tion.    McCurdy^  sawed  through  the  ulna,  leaving  the  extremity 


1  Transactions  American  Orthopedic  Association,  vol.  vi. 
-  Ibid.,  vol.  viii. 


494 


ORTHOPEDIC  SURGERY 


Fig.   312 


in  relation  to  the  carpus  and  sutured  the  proximal  fragment  and 
the  semihmar  bone  to  one  another.  Thomson^  rephiced  the  hand 
by  subcutaneous  tenotomy  and  by  the  removal  of  a  cuneiform 
form  section  of  bone  from  the  lower  end  of  the  ulna. 

The  operation  of  splitting  the  ulna  into  an  ulnar  and  radial 
portion  and  iinplanting  the  carpus  between  the  two  has  been 

performed  by  Bardenheuer.^  The 
immediate  effect  of  the  various 
operative  procedures  was  favorable, 
but  no  final  results  have  been  re- 
ported. 

In  any  event  some  form  of  appar- 
atus must  be  used  during  childhood 
at  least,  to  support  the  hand, 
whether  the  operation  has  been  suc- 
cessful or  not ;  and  at  best  the  arm 
will  be  short  and  the  thumbless  hand 
weak  as  compared  with  its  fellow. 

Congenital  Contraction  of 
the  Fingers. 

The  most  common  form  of  con- 
genital contraction  and  one  that  is 
sometimes  hereditary  is  that  of  the 
little  finger  (hammer  finger)  of  one 
or  both  hands.  This  is  semiflexed 
and  extension  is  checked  by  what 
ap|)ears  to  be  a  congenital  shorten- 
ing of  all  the  soft  parts  on  the  flexor 
side.  In  other  instances  several 
fingers  may  be  similarly  affected. 

Treatment. — If  treatment  by  ma- 
nipulation and  sj)linting  is  begun 
early  the  deformity  may  be  over- 
come by  lengthening  the  contracted 
tissue.  In  later  lilV;  tin;  prospect  of  perfect  cure  by  any  method  of 
treatment  is  slight,  becrause  of  tlu^  strong  tendency  to  recontrac- 
tion  after  llic  fingci-  lias  been  straightened. 


CoriKonital  ohil^-himils,  Hhowing  tlie 
short  ami  (Jefornied  forearirin,  also 
bow-legs.     (Gibney.) 


'  TrariMaclioriM  Aineiican  Oitlioitedic  A.sMocial  ion,  vol,  ix. 
-   Verhand.  dor  deutBch.  Gesella.  f.  Chir.,  2'.i  Kong.,  18'J4. 


DEFORMITIES  OF  THE  UPPER   EXTREMFPY  405 

Webbed   Fingers. 

In  the  most  common  form  of  this  deformity  two  or  more  fingers 
are  joined  by  skin  and  fibrous  tissue  to  the  first  phalangeal  joints, 
but  sometimes  throughout  the  entire  length  of  the  fingers. 

In  other  instances  the  web  may  be  thicker,  containing  muscular 
fibres  from  the  apposed  parts,  and,  occasionally,  the  hemes  of  the 
two  fingers  may  be  joined  to  one  another,  even  to  the  finger-nails. 

Etiology. — The  cause  of  the  deformity  is  arrest  of  develop- 
ment before  the  fingers  have  been  separated  from  one  another; 
thus  the  thumb,  which  is  differentiated  from  the  other  parts  of 
the  hand  as  early  as  the  seventy-fifth  day  of  intrauterine  life,  is 
rarely  involved,  as  compared  with  the  fingers,  which  are  separated 
from  one  another  at  a  later  period. 

Treatment. — In  all  but  the  extreme  grades  of  fleformity  the 
fingers  may  be  separated  from  one  another,  operative  treatment 
being  conducted  according  to  the  rules  of  plastic  surgery. 

Congenital  Displacements  of  the  Phalanges  and  Distortions 

of  the  Fingers. 

These  deformities  are  not  particularly  uncommon.  They  should 
be  treated  by  manipulation  and  by  splintmg  at  as  early  a  period 
as  is  practicable.  Other  congenital  deformities  and  malformations 
of  the  hand  do  not  call  for  extended  comment. 

Trigger   Finger. 

Synonyms. — Jerking  finger,  snapping  finger. 

This  affection  was  first  described  by  Nclaton  under  the  title 
"Doigt  a  Ressort."  On  extending  the  closed  hand  one  finger 
remains  flexed.  If  the  flexion  is  overcome  by  greater  nniscular 
effort  or  by  passive  force  the  finger  flies  back  to  comjilete  extension 
with  a  sudden  snap  or  jerk;  hence  the  name.  In  weil-niarked 
cases  the  same  difficulty  and  the  subsecjuent  snap  is  experienced 
in  flexing  the  finger.  The  middle  and  ring  fingers  are  more 
often  affected,  but  sometimes  the  thumb  or  the  fifth  finger  may 
be  involved. 

The  patient  usually  complains  somewhat  of  stitt'ness  and  pain 
in  the  finger,  l)ut  the  interference  with  its  function  is  the  prin- 
ci])al   symptom. 

Etiology. — The  cause  of  the  disability  is  interference  with  the 
motion  of  the  tendon  in  its  fibrous  sheath,  either  because  of  a 


496  ORTHOPEDIC  SUEGEBY 

reduction  of  its  calibre  due  to  injury  or  inflammation,  or  to  an 
enlargement  or  irregularity  of  the  tendon  itself.  In  most  instances 
the  obstruction  appears  to  be  in  the  neighborhood  of  the  meta- 
tarsophalangeal jomt/ 

The  duration  of  the  affection  is  indefinite. 

Treatment. — If  the  obstruction  appears  to  be  of  inflammatory 
or  traumatic  origin  it  may  be  treated  by  splinting  and  later  by 
massage.  In  confirmed  cases  the  tendon  and  the  sheath  may  be 
explored  in  the  hope  of  finding  and  removing  the  obstruction.^ 

Mallet   Finger. 

Sjaionym,— Drop-finger. 

This  is  caused  usually  by  a  blow  upon  the  terminal  phalanx, 
which  ruptures  or  weakens  the  attachment  of  the  extensor  tendon 
at  the  base  of  the  phalanx  so  that  it  is  habitually  flexed  some- 
times nearly  to  a  right  angle. 

The  treatment  must  be  by  incision  and  re-attachment  of  the 
tendon  to  the  periosteum. 

"Baseball  finger"  is  the  reverse  displacement  of  the  terminal 
phalanx,  which  is  dislocated  backward,  forming  a  bayonet-like 
deformity.  There  is  often,  in  addition,  injury  of  the  base  of  the 
phalanx  that  causes  subsequent  irregular  hypertrophy. 

If  reposition  is  impossible  open  incision  may  be  employed  to 
correct  the  deformity. 

Dupuytren's  Contraction. 

Dupuytren's  contraction  is  a  deformity  of  the  hand  caused  by 
contraction  of  a  part  of  the  palmar  fascia  and  of  its  prolongations 
to  one  or  more  of  the  fingers.  The  fingers  are  flexed  as  a  conse- 
quence to  a  greater  or  less  degree,  and  in  advanced  cases  they 
may  be  drawn  to  close  contact  with  the  palm.  The  ring  finger 
is  most  often  primarily  aft'ected,  but,  as  a  rule,  two  or  more  fingers 
are  somewhat  involved  in  the  contraction. 

In  a  large  proportion  of  the  cases  both  hands  are  affected, 
but  not  as  a  rule  simultaneously,  the  contraction  beginning  in  the 
second  hand  several  years  after  the  deformity  in  the  first. 

Pathology. — The  characteristics  of  the  deformity  are  explained 
by  the  anatomy  of  the  palmar  fascia.     This  consists  of  a  strong 

'   Marches,  Deutsch  Zeits.  f.  Chir.,  Bd.  Ixxix.,  p.  304. 

'■*  The  bibliography  is  larpsc.     More  recent  articles  are  those  of  Jamin,  Cent.  f.  Chir.,  June 
6,  1896,  who  reportu  thirty-one  caeeii,  and  A.  Necker,  Beitrilge  zur  klin.  Chir,,  B.  x.  p.  469. 


DEFORMITIES  OF  THE  UPPER  EXTREMITY  497 

central  portion,  and  two  thinner  lateral  parts  that  cover  the  mus- 
cles of  the  thumb  and  little  finger.  It  is  made  up  of  longitudinal 
fibres  continuous  with  the  tendon  of  the  palmarLs  longus,  and 
the  annular  ligaments.  It  divides  into  four  processes  that  are 
attached  to  the  digital  sheaths,  to  the  integument  at  the  clefts 
of  the  fingers,  and  to  the  superficial  transverse  ligament.  Pro- 
longations of  the  fascia  pass  along  the  lateral  aspect  of  the  fingers 
and  are  attached  to  the  periosteum  and  to  the  tendon  sheaths  of 
the  first  and  second  phalanges. 

The  cause  of  the  contraction  appears  to  be  a  chronic  plastic 
inflammation  of  a  part  of  the  fascia,  which  becomes  hypertrophierl 
and  finally  contracts,  drawing  the  finger  toward  the  palm  in  the 
manner  described. 

Etiology. — The  etiology  is  uncertain. 

The  contraction  is  much  more  common  in  men  than  in  women, 
and  it  is  practically  confined  to  middle  and  later  life.  It  is  claimed 
that  the  deformity  is  more  common  among  those  who  are  subject 
to  gout  or  rheumatism.  It  appears,  also,  to  be  an  hereditary 
affection  in  certain  instances.  Injury  or  irritation  of  the  palmar 
tissues,  incident  to  certain  occupations,  would  seem  to  explain 
the  disproportionate  liability  of  the  sexes  to  the  affection. 

Symptoms. — The  first  symptom  is  usually  the  deformity;  the 
patient  finds  it  impossible  to  completely  extend  one  or  more  of 
the  fingers;  the  tissues  about  the  base  of  the  finger  seem  stiff, 
and  when  it  is  forcibly  extendefl  a  hard,  elevated  cord  may  be 
felt  extending  from  about  the  centre  of  the  palm  to  the  second 
phalanx,  most  prominent  at  the  metacarpophalangeal  articulation. 

To  this  the  skin  is  adherent,  and  as  the  contraction  increases 
it  is  thrown  into  elevated  ridges.  Later  other  bands  appear  if 
the  contraction  affects,  as  it  usually  does,  other  portions  of  the 
fascia.  In  many  instances  no  pain  is  experienced  unless  the  con- 
tracted fascia  is  forcibly  stretched  or  is  passed  upon.  In  other  cases 
complaint  is  made  of  neuralgic  pain  in  the  hand  and  even  in  the 
arm  and  back.  Occasionally  the  first  symptom  to  attract  atten- 
tion may  be  a  sensitive  nodule  in  the  skin  at  the  base  of  the  finger. 

The  contraction  usually  increases  slowly  until  the  finger  that 
is  most  affected  is  drawn  to  the  palm. 

Treatment. — The  deformity  may  be  overcome  in  part  by  mul- 
tiple division  of  the  contracted  bands  from  the  finger  to  the  palm, 
but  complete  removal  of  the  contracted  fascia  is  preferable  if  it 
be  possible.  The  finger  is  then  supported  in  an  attitude  of  slight 
flexion  until  the  circulation  is  adjusted  to  the  new  position. 

32 


CHAPTER  XIV. 

CONGENITAL  AND  ACQUIRED  AFFECTIONS  LEADING  TO 
GENERAL  DISTORTIONS. 

Rhachitis. 

Synonym. — Rickets . 

Rhachitis  is  a  constitutional  disease  of  infancy  caused  by  de- 
fective nutrition,  of  which  the  most  marked  effect  is  distortion 
of  the  bones. 

Etiology. — The  predisposing  cause  is  constitutional  weakness. 
This  may  be  inherited  or  it  may  be  the  direct  effect  of  illness, 
but  most  often  it  is  the  result  of  improper  hygienic  surroundings, 
particularly  lack  of  sunlight,  damp  rooms,  overcrowding,  and  defec- 
tive ventilation.  The  direct  cause  of  the  disease  is  improper 
nourishment.  In  most  instances  this  is  due  to  the  substitution 
of  artificial  food  for  the  mother's  milk,  in  others  to  improper  diet 
after  the  infant  is  weaned;  in  rare  cases  it  may  be  the  result  of 
prolonged  lactation,  or  it  may  be  caused  by  the  defective  quality 
of  the  mother's  milk.  The  disease,  therefore,  begins  usually 
between  the  ages  of  six  and  eighteen  months,  although  it  is  by 
no  means  confined  to  these  limits.^  In  most  instances  improper 
surroundings  and  improper  nourishment  are  combined  in  the 
causation  of  the  disease;  thus  rhachitis  is  relatively  common  in 
large  cities.  At  the  Hospital  for  Ruptured  and  Crippled  the 
most  extreme  cases  are  observed  among  the  Italian  and  the  colored 
children.  The  former  are  usually  nursed,  but  are  improperly 
fed  after  weaning,  while  the  latter,  if  nursed  at  all,  are  usually 
allowed  a  mixed  diet  even  during  the  early  months  of  life. 

1  According  to  Baginsky  the  age  of  onset  in  023  cases  was  as  follows: 

Males.  Females.  Total. 

3    —    6     months 35  8  43 

6—12 

1     —     114  years 115 

VA—    2 


2  —     2'A 
2A—     3 

3  —     4 

4  —  13 


01 

72 

173 

15 

105 

220 

64 

49 

113 

18 

24 

42 

9 

12 

21 

2 

5 

7 

0 

0 

4 

844  276  623 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS     499 

Pathology. — The  manifestations  of  a  disease  dependent  upon 
impaired  nutrition  are,  of  course,  general  in  character.  In  rha- 
chitis  there  is  a  mild  degree  of  ansemia,  and  a  general  weakness 
and  relaxation  of  the  voluntary  and  involuntary  muscles.  As 
a  result  the  circulation  is  impaired  and  the  power  of  assimila- 
tion is  diminished;  thus  congestion  and  enlargement  of  the  internal 
organs,  intestinal  catarrh,  bronchitis,  and  the  like  are  common 
accompaniments  of  the  disease.  The  most  marked  and  char- 
acteristic changes  are  found  in  the  bones;  these  consist  in  a  dimi- 
nution of  the  earthy  substances  and  in  overgrowth  of  osteoid  tissue. 

"The  essential  features  of  the  morbid  processes  are,  first,  an 
exaggeration  of  the  processes  immediately  preparatory  to  the 
development  of  true  bone;  secondly  an  imperfect  conversion  of 
this  preparatory  tissue  into  true  bone;  and  thirdly,  a  great  irregu- 
larity of  the  whole  process."     (Erichsen.) 

On  section  of  rhachitic  bone  it  will  be  noted  that  the  perios- 
teum is  increased  in  thickness,  and  is  more  or  less  adherent  to 
the  underlying  softened  and  spongy  tissue.  The  medullary  canal 
is  enlarged,  and  its  contents  are  abnormally  vascular.  The 
epiphyseal  cartilage,  normally  a  thin,  bluish  line,  is  much  increased 
in  thickness.  It  appears  to  be  swollen  and  infiltrated,  and  it  has 
lost  its  former  translucency.  Microscopic  examination  at  this 
point,  where  growth  is  m.cst  active,  shows  marked  irregularity 
in  size  and  shape  of  the  columns  of  cartilage  cells;  the  zone  of 
calcification  is  lacking  or  is  ill-defined,  and  masses  of  cartilage 
cells  are  found  unchanged  in  what  should  be  the  area  of  true 
bone.  The  same  irregularity  of  line  and  shape  is  observed  in 
the  medullary  spaces  of  the  newly  formed  osteoid  tissue. 

As  a  direct  result  of  the  changes  that  have  been  described,  the 
epiphyseal  junctions  are  enlarged  and  the  shafts  of  the  bones  are 
thickened  by  the  formation  of  osteoid  tissue  beneath  the  perios- 
teum. The  indirect  effects  of  the  disease,  and  of  the  weakness 
that  it  causes  are  deformities,  the  nature  of  which  will  be  indi- 
cated inider  the  heading  of  symptoms.  The  stage  of  weakness 
is  followed  by  that  of  repair,  which  sometimes  goes  on  with 
great  rapidity;  the  softened  bones  become  abnormally  hard,  "ebur- 
nated,"  and  premature  solidification  at  the  epiphyseal  junctions 
may  be  one  of  the  remote  results  of  the  disease  that  accounts 
in  part  for  the  dwarfing  of  the  stature,  observed  as  one  of  the 
final  results  of  severe  rhachitis. 

Symptoms. — As  the  disease  is  the  effect  of  imperfect  assimi- 
lation its  more  pronounced  symptoms  are  preceded  by  those  of 


500  ORTHOPEDIC  SURGERY 

indigestion,  such  as  flatulence,  constipation,  and  the  like.  Pro- 
fuse perspiration,  especially  about  the  head,  and  restlessness  at 
night  are  common  symptoms.  Teething  is  often  delayed  or  is 
irregular.  The  infant  is  slow  in  its  movements,  and  makes  little 
effort  to  stand  or  to  walk  at  the  usual  time,  and  if  the  disease  is 
active  the  affected  parts  may  be  sensitive  to  pressure. 

Deformities.— The  deformities  are  in  part  due  to  the  direct  effect 
of  the  disease.  One  of  the  earliest  and  most  constant  evidences 
of  rhachitis  is  the  enlargement  about  the  epiphyses,  an  enlarge- 
ment caused  in  part  by  the  direct  hypertrophy  and  in  part  by 
pressure  upon  the  softened  tissues.  The  enlargements  at  the 
jimctions  of  the  ribs  and  the  costal  cartilages,  the  rhachitic  rosary, 
and  at  the  wrists  and  ankles,  double  joints,  are  almost  invariably 
present  in  well-marked  cases.  The  more  general  distortions  are 
in  part  the  effect  of  atmospheric  pressure,  in  part  the  effect  of 
the  force  of  gra\4ty  and  habitual  postures,  and  in  some  instances 
muscular  action  or  injury  may  deform  the  softened  bones.  These 
deformities  differ  greatly  according  to  the  time  of  onset  of  the 
disease,  and  with  its  duration  and  severity.  The  head  may  be 
long  and  oblong  in  shape,  or  rectangular,  caput  quadratum,  and 
it  sometimes  presents  prominences  in  the  frontal  and  parietal 
regions  due  to  thickening  of  the  bone,  and  on  the  posterior  aspect 
depressed  and  softened  areas,  craniotahes.  The  fontanelles  are 
abnormally  large,  and  they  may  remain  open  long  after  the  usual 
time  of  closure. 

The  thorax  is  compressed  from  side  to  side,  the  compression 
being  most  marked  in  the  middle  region,  where  the  ribs  have  the 
longest  cartilages  and  the  least  direct  support.  As  secondary 
results  the  back  of  the  thorax  is  flattened  and  the  sternum  is  thrust 
forward,  forming  the  'pigeon  breast.  The  lower  ribs  are  everted 
to  accommodate  the  distended  abdomen,  potbelly.  In  well- 
marked  cases  the  rhachitic  chest  presents  two  distinct  grooves: 
one  transverse  in  the  axillary  line,  Harrison's  groove,  and  the 
other  passing  upward  by  the  side  of  the  rhachitic  rosary.  These 
deformities  are  in  great  degree  caused  by  atmospheric  pressure, 
but  they  are  increased  if  the  child  assumes  the  sitting  posture 
habitually.  In  this  attitude  the  body  is  inclined  forward,  the 
clavicles  are  distorted,  and  the  spine  is  bent  into  a  more  or  less 
rigid  posterior  curve,  most  marked  in  the  lower  dorsal  and  lumbar 
regions,  the  rka/^hitic  kyphosis.  Less  often  there  may  be  a  lateral 
deviation  or  scoliosis. 

The  arms  may  be  distorted  by  the  eft'orts  of  the  child  to  support 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS     501 

the  body  in  the  sitting  posture,  or  by  active  exertion,  as  in  creeping 
(Fig.  313).  Occasionally  the  deformities  may  be  localized  at 
the  elbows,  and  sufficiently  marked  to  merit  the  name  cubitus 
varus  or  valgus,  corresponding  to  genu  valgum  or  varum;  or 
the  principal  distortion  may  be  a  dorsal  convexity  of  the  lower 
extremity  of  the  radius. 

Spindle-shaped  phalanges  are  sometimes  noted  among  the  early 
signs  of  rhachitis  in  young  children.^ 

Fig.   313 


General  rhachitic  deformities,  showing  distortions  of  the  arms  and  legs  induced  by  posture. 

The  bones  of  the  lower  extremities  are  often  distorted,  primarily 
by  the  habitual  postures  assumed  in  sitting  or  creeping,  and  these 
deformities  are  usually  exaggerated  when  the  erect  attitude  is 
assumed.  In  some  instances  it  would  appear  that  the  femoral 
necks  are  twisted  backward  somewhat;  this  distortion  induced 
apparently  by  the  cross-legged  attitude  of  sitting  may  explain  in 
part  the  limitation  of  inward  rotation  that  is  sometimes  observed 
in  rhachitic  children.  Depression  of  the  femoral  neck  (coxa 
vara)   may  be  present  also,  although   this  deformity  does  not, 

>  Neurath,  Wien  Klin.,  v.  xl.,  N.  1617. 


502  ORTHOPEDIC  SURGERY 

as  a  rule,  attract  attention  until  a  much  later  period  of  life.  The 
changes  in  the  pelvis  are  of  special  interest  to  the  obstetrician. 
These  are  essentially  an  increase  in  the  sacrovertebral  prominence 
due  to  the  forward  and  do\^^lward  displacement  of  the  sacrum, 
an  abnormal  expansion  of  the  ilia,  caused  by  pressure  of  the 
abdominal  contents,  and,  in  some  instances,  a  decrease  of  the 
lateral  diameter,  an  effect  of  the  pressure  of  the  femora  upon 
the  fielding  bone. 

In  the  milder  type  of  rhachitis  in  older  children  who  walk,  the 
deformities  are  often  confined  to  the  trunk  and  lower  extremities. 
In  such  cases,  in  addition  to  the  changes  in  the  bones,  there  is 
usually  a  prominent  abdomen  and  increased  lordosis,  combined 
with  slight  habitual  flexion  of  the  thighs  and  lower  legs,  the  rhachitic 
attitude. 

If  the  disease  is  of  sudden  onset  and  is  severe  and  general  in 
its  manifestations  it  may  be  accompanied  by  pain,  by  sensitive- 
ness of  the  affected  bones,  and  by  such  weakness  of  the  lower 
extremities  as  may  simulate  paralysis,  rhachitic  pseudoparalysis. 
It  is  probable,  however,  that  the  cases  in  which  the  pain  is  extreme, 
"acute  rhachitis,"  are,  in  reality,  scurvy  or  scurvy  and  rhachitis 
combined,  scurvy  rickets  so-called. 

Rhachitis,  as  described,  is  the  type  ordinarily  seen  in  hospital 
practice,  and  its  manifestations  are  unmistakable.  In  its  milder 
form  it  is  not  particularly  uncommon  among  the  children  of  the 
w'ell-to-do,  whose  hygienic  surroundings  are  good.  In  such 
cases  the  most  marked  symptom  is  weakness.  The  child  is 
often  fat  and  well  developed,  although,  as  a  rule,  pale.  The 
abdomen  is  somewhat  enlarged  and  slight  prominences  at  the 
epiphyseal  junctions,  particularly  at  the  wrists,  may  be  made  out. 
The  legs  appear  small  in  proportion  to  the  body,  and  the  liga- 
ments are  lax,  so  that  if  the  child  stands  the  feet  are  flat  and 
assume  the  attitude  of  valgus.  In  this  class,  in  which  the  child 
is  said  to  have  weak  ankles,  knock-knee  is  common. 

The  most  common  symptom  of  rhachitis  of  the  mild  type  is  the 
failure  of  the  child  to  attempt  to  walk  at  the  usual  time,  about 
sixteen  months.  A  child  of  normal  intelligence  who  is  not  ill  and 
who  has  not  suffered  from  exhausting  disease  and  does  not  walk  at 

o 

tvvrj  years  of  age  is  probably  rhachitic. 

Prognosis. — The  duration  of  the  progressive  stage  of  rhachitis 
depends,  of  course,  upon  the  age  of  the  patient  and  upon  the  treat- 
ment. In  cases  that  are  untreated  and  in  which  the  predisposing 
causes  contiruie,  the  period  of  repair  may  be  delayed  for  several 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS      503 

years  or  longer,  as  shown  by  the  fact  that  the  child  makes  little 
effort  to  stand.  But,  in  most  instances,  the  rhachitic  child  begins 
to  walk  at  some  time  during  the  third  year,  and  at  this  time  the 
deformities  of  the  lower  extremity,  knock-knee,  bow-leg,  fiat-foot, 
and  the  like  usually  develop  or  become  aggravated,  while  those 
of  the  upper  extremity  may  become  less  noticeable. 

The  deformities  of  rhachitis  tend  to  disappear  or  to  become 
less  marked  with  growth;  the  concavities  of  the  distorted  shafts 
are  filled  by  accretions  of  periosteal  bone,  which  is  again  absorbed 
from  the  interior  as  the  medullary  canal  straightens  itself.  The 
thickened  diaphyses  and  enlarged  epiphyses  }:)ecome  more  sym- 
metrical under  the  influences  of  rapid  growth  and  increased  func- 
tional activity,  but  traces  of  severe  rhachitis  always  remain,  and 
many  of  the  more  noticeable  and  permanent  distortions  of  the 
trunk  and  of  the  lower  extremities  are  due  to  this  cause. 

The  prognosis  as  to  the  outgrowth  of  rhachitic  deformities 
depends  upon  the  duration  and  the  severity  of  the  disease  and 
upon  the  function  of  the  deformed  part.  Rhachitic  distortions 
of  the  arms  almost  always  disappear.  The  rhachitic  chest  is 
rarely  seen  in  the  adolescent  or  adult.  The  rhachitic  kyphosis 
is  corrected  or  modified  when  the  erect  posture  is  assumed,  but 
rhachitic  scoliosis,  on  the  other  hand,  usually  increases  with  the 
growth.  Distortions  of  the  lower  extremities  may  occasionally 
entirely  disappear,  and  in  most  cases  they  are  less  marked  in  the 
adult  than  in  the  child.  Stunting  of  the  growth  is  a  constant 
effect  of  severe  and  prolonged  rhachitis;  it  depends  in  part  upon 
the  arrest  of  development  during  the  active  stage  of  disease  and 
in  part  upon  the  changes  in  the  bones  that  cause  premature  con- 
solidation at  the  epiphyses. 

Treatment. — The  treatment  of  rhachitis  consists  essentially 
in  a  reversal  of  the  conditions  under  which  it  developed.  It 
is  therefore  dietetic,  hygienic,  and  medicinal.  Deformity,  the 
effect  of  the  disease,  may  be  prevented  by  guarding  the  weakened 
bones  from  overstrain,  and  it  may  be  remedied,  if  it  be  present, 
by  manipulation  or  by  mechanical  or  by  operative  treatment. 

The  more  detailed  treatment  of  rhachitis  may  be  found  in 
works  on  Pediatrics.  In  general,  the  diet  in  the  cases  developing 
in  early  infancy  should  be  of  milk,  especially  modified  according 
to  the  need  of  the  patient.  At  a  later  time,  corresponding  to  the 
normal  period  of  weaning,  the  diet  should  be  largely  animal,  to 
the  exclusion  of  starchy  food,  cream  and  fresh  butter  being  espe- 
ciallv  valuable. 


504  OUTHOPEDIC  SUBC^ERr 

The  patient,  protected  bv  proper  woollen  underclothing,  should 
pass  as  much  time  as  possible  in  the  open  air,  and  should  sleep 
in  a  well-ventilated  room.  Daily  salt  baths  are  recommended 
for  older  children,  antl  regular  massage  of  the  extremities  and  of 
the  abdomen  should  be  employed.  jNIedicinal  treatment  is  of 
secondary  importance.  The  bowels  should  be  regulated  and 
digestion  should  be  aided  by  proper  remedies.  For  anaemia, 
which  is  usually  present,  the  syrup  of  the  iodide  of  iron  is  of 
value;  cod-liver  oil  serves  both  as  a  food  and  medicine,  when  it 
is  readily  assimilated.  It  is  unlikely  that  any  drug  has  a  very 
direct  influence  on  the  disease.  Phosphorus  in  doses  of  ^^  to 
Y^  of  a  grain  is  often  given,  and  is  supposed  to  lessen  the  abnor- 
mal congestion  of  the  bones,  while  the  deficiency  of  lime  salts 
may  be  supplied  possibly  by  the  administration  of  lime  in  some 
form,  the  syrup  of  the  lactophosphate  of  lime  being  a  favorite 
prescription. 

The  prevention  of  deformity,  other  than  by  the  means  already 
enumerated,  consists  in  preventing  habitual  postures  that  predis- 
pose to  deformity,  and  in  daily  massage  and  manipulative  cor- 
rection of  incipient  distortions.  Young  infants  and  those  whose 
bones  are  especially  vulnerable  should  spend  much  of  the  time 
in  the  reclining  posture.  The  Bradford  frame  or  similar  appli- 
ance is  especially  useful  in  the  treatment  of  this  class  of  cases. 
The  treatment  of  the  more  advanced  deformities,  by  support  or 
by  operation,  is  described  elsewhere. 

"Late    Rickets." 

Late  rickets  is,  as  the  name  implies,  an  affection  presenting 
all  the  characteristics  of  the  common  infantile  form.  This,  in 
rare  instances,  appears  in  later  childhoot[  or  even  in  adolescence; 
in  some  cases  the  affection  appears  to  be  a  continuation  or  recru- 
descence of  the  infantile  form;  in  others  no  history  of  a  preced- 
ing affection  can  be  obtained.^ 

By  many  writers  the  term  late  rickets  is  improperly  used  to 
explain  the  deformities  of  adolescence,  genu  valgum,  coxa  vara, 
and  the  like,  although  none  of  the  distinctive  signs  of  the  affec- 
tion may  })e  present.  Local  rickets  is  less  objectionable  as  applied 
to  the  same  class  of  cases. 


'  Drewitt,  Transactions  of  the  London  Pullioloxioal  Society,  1881,  vol.  xxxii.     Cluttoii, 
•St.  Thornan'   Hospital   Heports,   1884,  vol  xiv. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS     505 

Chondrodystrophia. 

Synonyms. — Foetal  rhachitis,  achondroplasia. 

Cases  that  present  the  signs  of  what  appears  to  be  severe  general 
rhachitis  at  birth  are  not  especially  uncommon.  The  trunk  is 
disproportionately  long  as  compared  to  the  stunted  limbs;  the 

Fig.  314 


Chondrodystrophia  of  slight  degree,  contrasted  with  ordinary  rhachitis,  in  sisters.  1.  Chon- 
drodystrophia. Broad,  short,  very  flexible  hands;  trunk  disproportionately  long;  knock- 
knees.  Age,  five  and  a  h.alf  years;  height,  30^2  inches;  normal  height.  40  inches.  2.  Rha- 
chitis, bow-legs;  age,  four  years;  height  32  inches;  normal  height,  .SO  inches. 

head  is  large.  The  face  is  flattened  and  the  skin  may  be  tliicktMiing, 
the  chest  presents  a  pigeon-like  distortion,  and  the  epiphyses 
appear  to  be  generally  enlarged.  In  some  instances  the  back 
is  curved  into  a  rigid  kyphosis,  or  .scoliosis  and  restricted  motion 
or  apparent  fixation  of  many  of  the  joints  may  be  present,  in  others 
the  joints  are  practically  normal.^ 

^  Rocs,  Zeits.  f.  klin.  Mod.,  vol.  xlviii. 


506  OUTHOPEDIC  SUEGERY 

Etiology  and  Pathology. — These  cases  were  formerly  sup- 
posed to  be  instances  of  intrauterine  rliachitis.  Chondrodystrophia 
is  not,  however,  the  result  of  a  disturbance  of  nutrition;  it  is  due 
apparently  to  a  congenital  defect  in  the  bones  themselves  or  rather 
of  the  original  cartilage.  Rliachitis  is  characterized  bv  thickening 
about  the  epiphyseal  cartilages  and  by  delayed  ossification.  In 
chondrodystrophia,  on  the  contrary,  there  is  atrophy  of  the  epi- 
physeal cartilages  and  abnormal  rapidity  of  ossification.  On 
section  of  a  bone  the  shaft  is  seen  to  be  thickened  and  stunted, 
the  epiphyses  are  enlarged  also,  and  these  hypertrophied  and 
prematurely  ossified  segments  may  overhang  the  diminutive  car- 
tilage that  intervenes  and  which  may  be  partly  or  completely 
inclutled  in  a  periosteal  expansion  of  connective  tissue. 

Chondrodystrophia,  or  an  affection  resembling  it,  is  sometimes 
seen  (Fig.  314)  in  a  very  mild  form;  the  appearance  of  the  child 
suggests  rhachitis,  but  the  stunting  of  the  growth  is  greater  than 
is  ever  the  result  of  rhachitis  of  corresponding  severity. 

Cretinism. — Cretinism  may  cause  a  similar  dwarfing  of  the 
stature,  and  may  be  combined  with  chondrodystrophia,  but  in 
most  instances  the  symptoms  of  mental  deficiency  that  accompany 
cretinism  are  lacking  in  this  afl^ection. 

Treatment. — The  treatment  of  so-called  foetal  rhachitis  con- 
sists in  regular  massage  and  manipulation  of  the  distorted  parts 
and  of  the  anchylosed  joints.  This  treatment  must  extend  over 
several  years,  during  which  the  limbs  and  back  must  be  protected. 

Rest  on  the  Bradford  frame  during  the  period  of  active  treat- 
ment is  advisable.  If  congenital  cretinism  is  suspected  the 
administration  of  thyroid  extract  would  be  indicated. 

Prognosis.— By  persistent  treatment  the  range  of  motion  in 
the  stifteiied  joints  may  be  regained,  but  the  prognosis  as  to 
growtli  is  l>ad.  The  patients  present  in  later  years  the  abnor- 
mally long  trunk  and  stunted  extremities  that  were  present  at 
birth. 

Infantile   Scorbutus. 

Synonyms. — Scurvy,  scurvy  rickets. 

Scurvy  in  infancy,  as  at  otlici-  jx'riods  of  life,  is  a  constitutional 
disease  dependent  upon  impaired  nutrition,  caused  apparently 
y)y  the  deprivation  of  pi-ojjcr  food.  The  disease;  was  originally 
descrllK'd  l)y  Smith  and  Harlow  as  scurvy  rickets,  })ut  it  may, 
and  often  does,  (;ccur  indepenciently  of  tlu;  latter  alfcction. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS    507 

Pathology.— The  pathological  changes  most  often  found  in 
cases  of  the  advanced  type  are  hemorrhages  beneath  the  mucous 
membranes  and  the  periosteum.  Separation  of  the  epiphyses 
may  occur. 

Symptoms. — The  disease  is  most  often  observed  in  bottle-fed 
infants  from  six  to  eighteen  months  of  age.  In  some  instances  the 
patients  are  evidently  ill-nourished,  but  in  others  they  may  appear 
to  be  in  good  condition.  The  early  symptoms  resemble  rheu- 
matism. The  child  shows  evidences  of  discomfort  when  certain 
joints,  usually  of  the  lower  extremity,  are  moved,  and  as  the 
disease  progresses  it  may  scream  whenever  it  is  turned  or  lifted. 
The  painful  joints  are  sensitive  to  pressure  and  they  may  be 
somewhat  enlarged,  but  local  heat  and  redness,  as  well  as  fever, 
are,  as  a  rule,  absent.  After  dentition  the  gums  may  be  swollen 
and  spongy,  and  hemorrhages  into  the  skin  or  beneath  the  mucous 
membranes  may  occur.  In  extreme  cases  the  swelling  about  a 
joint  due  to  effusion  of  blood  and  accompanied,  it  may  be,  by 
separation  of  the  epiphysis  may  be  mistaken  for  the  symptoms 
of  infectious  epiphysitis  or  even  for  sarcoma. 

Treatment. — The  treatment  consists  primarily  in  the  regula- 
tion of  the  diet,  particularly  in  the  substitution  of  fresh  milk, 
properly  modified,  for  the  patent  food  or  sterilized  milk  that 
may  have  been  employed.  This  should  be  supplemented  by 
orange-juice  or  that  of  other  fresh  fruit.  The  change  of  diet 
usually  relieves  the  symptoms.  During  the  painful  stage  of  the 
disease  complete  rest  in  the  horizontal  position  on  a  pillow  or 
frame  may  be  indicated;  later,  massage  of  the  limbs  and  back 
may  be  of  service  in  improving  the  nutrition  and  remedying 
slight  deformity. 

Fragilitas  Ossium. 

Synonym.— Idiopathic  osteopsathyrosis. 

Idiopathic  fragility  or  osteopsathyrosis  is  of  congenital  origin. 
The  bones,  particularly  those  of  the  lower  extremity,  are  delicate 
in  structure  and  usually  short.  The  epiphyseal  cartilages  appear 
to  be  relatively  normal  but  the  periosteal  growth  of  bone  is  d(>fi- 
cient.  In  such  cases  there  may  be  distortions  ;it  birth,  aj)j)arently 
caused  by  intrauterine  fractures,  and  in  after-Hfc  fracture  may 
follow  the  slightest  accident  or  even  sud(l(>n  motion.  BlanciianP 
has  reported  a  case  in  which  there  were  seventy  distinct  fmctures 

'  Transactions  Amerioan  Orthnjjedic  Association,  vol.  vi. 


508  ORTHOPEDIC  SURGERY 

between  the  ages  of  two  months  and  twenty-seven  years.  A 
suuilar  case  was  for  many  years  nnder  treatment  in  the  Hospital 
for  Ruptured  and  Crippled.  For  a  part  of  the  time  the  trunk 
and  legs  were  enclosed  in  a  plaster-of-Paris  casing  to  prevent  the 
fractures  that  followed  even  ordinary  movements.  At  the  age 
of  fourteen  the  strength  of  the  bones  had  increased  sufficiently 
to  enable  the  patient  to  walk  about  with  the  support  of  braces, 
but  in  stature  he  resembled  a  chiUl  of  seven  years. 

Fractures  in  this  class  of  cases  are  attended  with  but  little 
pain.  They  unite  slowly  with  but  a  small  callus.  It  is  prac- 
tically impossible  to  prevent  a  certain  amount  of  deformity. 
With  advancing  years  the  liability  to  fracture  may  diminish, 
but,  as  a  rule,  the  patient  is  disabled  and  dwarfed  in  stature. 

The  treatment  is  protective.  Massage  is  of  some  service  in 
improving  local  nutrition.     Medication  is  of  little  avail.^ 

There  are  many  other  conditions  that  cause  local  or  general 
fragility  of  the  bones  and  thus  an  increased  liability  to  fracture. 
Among  the  local  causes  are  tumors,  cysts,  inflammatory  processes, 
syphilis  and  the  like.  The  general  conditions  would  include  the 
weakness  of  old  age,  sometimes  called  senile  rickets;  the  atrophy 
caused  by  disuse  incidental  to  chronic  joint  disease,  or  the  weak- 
ness that  may  be  caused  by  certain  diseases  of  the  nervous  system. 
In  other  instances  the  weakening  may  be  the  direct  result  of 
disease,  as,  for  example,  osteomalacia  or  rhachitis.  (See  Atrophy 
of  Bone,  page  244.) 

Osteomalacia.  ; 

Synonym. — MollitLs  ossium. 

Osteomalacia  is  a  disease  of  an  inflammatory  nature,  charac- 
terized by  an  absorption  of  the  earthy  substances  (decalcification) 
of  the  })f)nes  and  by  deformity.  The  disease  is  particularly  one  of 
adult  life.  It  is  far  more  common  among  females  than  males,  and 
pregnancy,  in  about  half  of  the  cases  that  have  been  reported, 
seemed  to  hv  tlic  exciting  cause.  The  disease  usually  begins 
insidiously.  The  symj)toms  are  pain  on  motion,  referred  to  the 
pelvis  and  to  the  thighs.  This  is  supposed  to  be  of  rheumatic 
origin  until  the  character  of  the  affectif)n  is  made  evident  by  the 
weakness  of  the  limbs  and  by  the  deformities.  These  deformities 
are  of  greater  interest  to  the  obstetrician  than  to  the  surgeon,  for 
when  the  affection  complicates  pregnancy  the  distortion  of  the 
pelvis  may  be  so  great  as  to  prevent  normal  delivery. 

'  Porak,  Bull,  et  Mdrn.  de  la  Soc.  Obst.  et  Gyn.  de  Paris,  1840.  Salvetti,  Beilr.  zur 
palli.  Aiiat.  uii'l  alln.  Path.,  1S94,  Ud.  xvi.   Niitliuri,  Airier.  Jour.  Med.  Sci.,  Kebruary,  1905. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS    509 

Osteomalacia  in  Childhood. — ^Three  cases  of  osteomalacia  in 
childhood  have  been  reported  by  Siegert/  and  one  case  has  come 
under  my  observation.  The  patient,  one  of  twelve  living  children 
of  healthy  parents,  was  nursed  by  his  mother  for  the  usual  period, 
and  until  the  age  of  four  years  he  appeared  to  be  perfectly  healthy. 
At  this  time,  without  known  cause,  general  weakness  became 
apparent,  and  at  the  same  time  deformities  of  the  lower  extremi- 

FiG.   315 


Osteomalacia  in  a  child. 

ties  developed.  At  the  age  of  six  years  he  was  unable  to  stand. 
The  condition  of  the  patient  at  nine  years  of  age  is  shown  in  Fig. 
315.  There  was  no  evidence  of  rhachitis  or  of  paralysis.  The 
patient  had  never  suffered  from  pain  or  discomfort.  The  lower 
extremities  were  somewhat  atrophied  from  disuse,  the  bones  were 
abnormally  flexible  and  were  distorted  to  a  moderate  degree. 
The  epiphyses  were  not  enlarged. 

Treatment. — As  the  etiology  of  the  affection  is  unknown,  the 
treatment  is  therefore  experimental  or  symptomatic  and  palliative. 

^  Munch,  med.  Woehenschr.,  November  1,  1898. 


510  ORTHOPEDIC  SURGERY 

Local  Osteomalacia. — AMien  deformity  of  a  bone  appears  and 
increases  without  apparent  cause  it  is  often  assumed  that  a  local 
disease— "local  rickets  or  local  osteomalacia"^ — is  present. 

Local  weakness  and  deformity  may  be  caused  by  injury  or  by 
subacute  osteomyelitis  and  the  like.  If  there  is  a  distinct  local 
disease  that  deserves  the  name  of  local  osteomalacia  its  cause 
has  not  been  determined. 


Osteitis   Deformans. 

This  disease  was  first  described  by  Paget^  in  1877.  It  is  a 
chronic  inflammatory  affection  of  the  bones,  characterized  by 
hypertrophy  and  softening.  "The  bones  enlarge,  soften,  and  those 
bearing  weight  become  unnaturally  curved  and  misshapen." 

Fig.    316 


Osteitis  deformans  in  a  female  seventy-three  years  of  age.      (Lunn.-) 

Section  of  an  affected  bone  shows  it  to  be  markedly  increased 
in  size,  and  somewhat  in  length,  by  a  combination  of  rarefying 
and  formative  osteitis.  The  inner  layers  become  porous,  and  at 
the  same  time  new  bone  is  deposited  beneath  the  periosteur(i. 

The  disease  ap})cars  to  be  confined  to  adult  life,  and  it  is 
apparently  more  common  among  males  than  females.  Of  67 
cases  collected  by  Packard,  Steele,  and  Kirkbride,^  61  per  cent, 
were  in  males. 

As  a  rule,  the  lesions  are  symmetrical  and  general  in  dis- 
tribution, tlic  bf)ii('s  of  the  lower  extremity,  the  skull,  and  the 
spine  being  mc^re  (if ten  involved.  Thus  the  head  progressively 
increases  in  size,  and  the  legs  become  bowed.     If  the  spine  is 

'  Med.  Chip.  TranH.,  vols.  .\l.  !in<l  Ixv. 

-  Prince,   Atnerican  .lournal  of  tlif;  Medical  Sciences,  November,  1902. 

"  American  .(ourn.il  of  \\u:  .Medical  Sciences,  November,  1901. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS     511 


affected  it   bends   forward,   forming  a   long,   more   or  less   rigid 
kyphosis. 

Aside  from  the  deformities  and  the  characteristic  enlargement 
of  the  bones,  the  symptoms  are  not  marked.  At  times  complaint 
is  made  of  pain  usually  supposed  to  be  rheumatic  until  the  char- 
acteristic changes  in  the  bones  appear.  The  disease  is  extremely 
chronic  in  its  course,  and,  as  a  rule,  the  general  health  is  not 
seriously  affected.  In  several  instances  sarcoma  of  bone  finally 
caused  death  many  years  after  the  onset  of  the  disease.  Its 
etiology  is  unknown,  and  its  treatment  is  palliative. 


Fig.   317 


Fig.  318 


Normal  tibia  and  foot. 


Osteitis  deformans.  Hyperostosis  and 
decalcification.  (Fitz.)  Contrast  with  Fig. 
317. 


Local  Osteitis  Deformans. — A  disease  resembling  in  its  general 
characteristics  osteitis  deformans  may  appear  in  a  single  bone 
or  in  corresponding  bones  of  the  lower  extremity  (Fig.  319).  It 
may  persist  indefinitely,  with  but  little  tendency  toward  the  general 
involvement  of  the  bones  characteristic  of  Paget's  disease,  whether 
it  is  a  variety  of  osteitis  deformans  or  is  of  another  class  is  not 
apparent  at  present.  The  treatment  is  symptomatic,  being  directed 
especially  toward  relief  of  strain  that  induces  discomfort  and  in- 
creases the  deformity. 


512 


ORTHOPEDIC  SURGERY 


Fig.   319 


Secondary   Hypertrophic   Osteoarthropathy/ 

Osteoarthropathy  is  an  inflammatory  disease  of  the  bone  char- 
acterized by  hypertrophy,  chibbing  of  the  fingers,  and  effusion 
into  certain  of  the  joints.  The  hypertrophy  is  caused  by  a  deposi- 
tion of  layers  of  bone  beneath  the 
periosteum  of  the  metacarpal  and 
metatarsal  bones,  the  phalanges  and 
the  distal  extremities  of  the  adjoining 
bones  of  the  arms  and  legs.  Less 
often  the  area  of  the  disease  is  more 
extensive,  involving  the  femora,  the 
humeri,  and  the  spine  even. 

Osteoarthropathy  is  usually  a  com- 
plication of  pre-existing  chronic  dis- 
ease, most  often  of  the  lungs.  The 
patient  first  notices  clubbing  of  the 
terminal  phalanges  and  hypertrophy 
of  the  finger-nails,  later  an  increasing 
enlargement  of  the  wrists  and  ankles, 
and  of  the  hands  and  feet,  accom- 
panied by  discomfort,  sensitiveness 
to  pressure,  and  often  by  effusion  into 
the  neighboring  joints,  symptoms  that 
would  be  classed  as  rheumatic  were 
it  not  for  the  evident  hypertrophy. 

The  clubbing  of  the  fingers  is  due, 
in  part  at  least,  to  impairment  of  the 
circulation,  and  the  connection  of  the 
disease  of  the  bones  with  that  of  the 
lungs  has  suggested  the  theory  that 
it  is  caused  by  the  absorption  of 
toxins,  and  that  its  etiology  is  similar 
to  the  amyloid  hypertrophy  of  the 
internal  organs  that  sometimes  fol- 
lows chronic  disease  of  bones  and 
joints  attended  by  suppuration.  The  treatment  is  symptomatic, 
and  as  the  affection  is  ahnost  always  secondary  to  graver  disease, 
but  httle  Is  known  of  its  outcome.  It  is  certain,  however,  that  the 
secondary  osteoarthropathic  symptoms  become  less  marked  or  may 


Osteitis  fleforraans  of  both  femora 
most  marked  on  the  right  side.  Dura- 
tion |of  symptoms  3  years.  Symp- 
toms increasing  outward  bowing  of  the 
limbs,  also  pain  and  weaiciie.ss  after 
overexertion. 


'  Marie,   Kevue  Mddicale,  Paris,  1890,  x.  p.  1.      Uiunburgor,    Wiener  klin.  Wouh.,  1889, 
No.  11;  Deutsche  Chir.,  1899.  L.  28. 


AFFECTIONS  LEADING  TO  GENERAL  DISTORTIONS    513 

even  disappear  as  the  patient  recovers  from  the  original  disease  of 
the  lungs  or  other  organs.  The  affection  is  very  uncommon  in 
childhood.  In  one  characteristic  case  observed  by  the  writer  com- 
plete recovery  followed  the  cure  of  Pott's  disease  and  chronic 
bronchitis,  the  hypertrophied  phalanges  alone  remaining.^ 

Acromegalia. 

This  affection  is  also  characterized  by  progressive  enlargement 
of  the  hands  and  feet,  but  it  differs  from  osteoarthropathy  in  that 
all  the  tissues  are  involved  in  the  hypertrophy.  The  hypertrophy 
of  the  bone  is  limited  to  the  extremities,  and  is  slight  compared 
with  that  of  the  soft  parts.  The  face  is  often  involved,  tlie  tissues 
of  the  nose,  lips,  and  ears  being  enlarged  and  thickened,  together 
with  the  underlying  bones,  so  that  the  expression  is  very  markedly 
changed. 

Acromegalia  is  common  among  those  of  gigantic  stature,  the 
local  hypertrophy  and  the  gigantism  both  being  due,  it  is  sup- 
posed, to  disease  of  the  pituitary  gland. 

Diagnosis. — The  three  affections  that  have  been  described — 
osteitis  deformans,  osteoarthropathy,  and  acromegalia — are  rare 
diseases,  and  they  are  of  little  practical  interest  to  the  surgeon 
other  than  from  the  standpoint  of  diagnosis.  This  might  be 
somewhat  difficult  if  the  pathological  process  were  confined  to  a 
single  bone  or  limb,  as  is  sometimes  the  case  in  osteitis  deformans. 

The  essential  characteristics  of  the  three  diseases  may  be  sum- 
marized as  follows:  In  osteitis  deformans  the  entire  bone  is 
increased  in  size  and  length,  and  because  of  the  coincident  weak- 
ening of  its  structure  it  becomes  distorted;  the  skull  is  usually 
involved,  but  the  hands  and  feet  are  not  often  affected.  It  is  a 
disease  of  middle  or  later  life,  and  there  are,  as  a  rule,  no  symp- 
toms other  than  those  due  to  the  local  changes  in  the  bones. 

In  osteoarthropathy  the  process  is  an  hypertrophy  of  a  slight 
degree,  caused  by  deposition  of  periosteal  bone,  especially  about 
the  distal  extremities  of  the  shafts  of  the  bones  adjoining  the 
hands  and  feet.  It  is  not  often  accompanied  by  the  weakness  or 
the  deformity  that  is  characteristic  of  the  preceding  affection; 
the  sknll  is  not  usuallv  involved,  but  the  long;  bones  of  the  hand 
and  feet  are  thickened,  so  that  these  members  are  marketiiy 
increased  in  size.     There  is  often  coincident  discomfort  and  swell- 

1   Whitman,  Pediatrics,  February  15,   1899. 
33 


514  ORTHOPEDIC  SURGERY 

iiig  of  the  neighboring  joints.  As  a  rule,  the  local  ali'ection  of 
the  bones  is  secondary  to  chronic  disease  of  the  lungs. 

In  acromegalia  the  marked  changes  are  hypertrophic  enlarge- 
ments of  the  hands  and  feet  in  which  all  the  tissues  are  involved; 
the  hypertrophy  of  the  bones  is  most  marked  about  the  epiphyses, 
the  diaphyses  remaining  unaffected;  thus  it  differs  from  the 
preceding  disease,  in  which  similar  enlargement  of  the  extremities 
occurs.  The  head  is  often  involved,  but  the  hypertrophy  is  of 
all  the  structures  of  the  face,  not  of  the  skull,  as  in  osteitis 
deformans. 

The  disease  appears  to  be  confined  to  early  adult  life,  and 
it  is  often  preceded  or  accompanied  by  symptoms  of  a  general 
nature,  headache,  mental  impairment  and  the  like. 

The  changes  in  the  bones  characterizing  the  affections  may  be 
easily  demonstrated  by  means  of  the  Roentgen  pictures. 


CHAPTER    XV. 

CONGENITAL  DISLOCATION  OF  THE  HIP  AND  COXA  VAliA. 

Congenital  Dislocation  at  the  Hip-joint. 

Of  all  the  congenital  dislocations,  or,  perhaps,  more  properly, 
misplacements,  that  of  the  hip-joint  is  by  far  the  most  common 
and  the  most  important. 

Statistics. — Congenital  dislocation  of  the  hip  is  much  more 
common  inUemales  than  in  males.     In  1362  cases  collected  from 


Fig.   320 


.8^!?.V 


Congenital  dislocation  of  the  hip,  showing  the  elongated  capsule  and  the  right-angled 
relation  of  the  neck  to  the  shaft  of  the  femur.     (William  Adams.) 

different  sources  by  Hoffa,  1189  (87.2  per  cent.)  were  in  females 
and  173  (12.7  per  cent.)  in  males.  Of  1039  cases  seen  at  the 
PolycHnic  in  Milan,  867  (83.4  per  cent.)  were  in  females,   172 


516  OR  TH  OPE  Die  SURGERY 

(16.6  per  cent.)  in  males. ^  In  SOI  cases  from  the  records  of  the 
Hospital  for  Ruptured  and  Crippled,  655  (81.6  per  cent.)  were 
in  females  and  146  (18.3  per  cent,)  in  males. 

The  dislocation  is  more  often  unilateral  than  bilateral.  In 
Hoffa's  series  of  1362  cases  860  (63.1  per  cent.)  were  single;  392  of 
the  right,  468  of  the  left  side.  In  502  cases  (36.9  per  cent.)  the 
displacement  was  bilateral. 

Statistics  of  801  Cases  of  Congenital  Dislocation  of  Hip,  Recorded 
AT  THE  Hospital  for  Ruptured  and  Crippled. 

Per  cent. 

Males 146  18.35 

Females 655  81.65 

801  100.00 

Right  hip 206  26.07 

Left  hip 353  44.69 

Both 231  29.24 

790  100.00 

Not  specified 11 

801 

Males. 

Right  hip 43  30.49 

Left  hip 55  39.02 

Both 43  30.49 

141  100.00 

Not  specified 5 

146 

Females. 

Right  hip 163  25.10 

Left  hip 298  45.94 

Both 188  28.96 

649  100.00 

Not  specified 6 

655 

"^rhe  dislocation  at  the  time  when  the  patients  are  brought  for 
treatment  is  usually  posterior,  upon  the  dorsum  of  the  ilium;  in 
other  instances  it  is  anterior,  and  the  head  of  the  bone  may  be 
felt  beneath  the  anterior  superior  spine.  It  is  probable,  however, 
that  the  primary  displacement  is  often  directly  upward,  for  in 
those  cases  discovered  in  infancy  this  position  is  common. 

Pathology. — The  pathological  anatomy  of  the  dislocation  was 
first  clearly  demonstrated  by  Dupuytrcn  in  1826,  and  since  1890, 
when  the  o|>cn  o})eration  was  first  performed,  the  exact  relation 
and  the  appearances  of  the  different  components  of  the  joint  have 
bcfu  dcscrilx'd  in  detail  by  Iloffa,  IjOxvwa,  and  other  operators. 

'   HcriKicclii,   Zeil-s.  Orth.  Chir.,  vol.  ii.  p.  275. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     517 


The  condition  of  the  joint  varies  with  tl)e  age  of  the  patient 
and  the  strain  and  friction  to  which  the  displaced  parts  have 
been  subjected.  In  early  infancy  it  may  be  assumed  that  the 
head  of  the  bone  lies  in  close  proximity  to  what  is,  in  some  in- 
stances, a  practically  normal  acetabulum;  in  others  to  one  that 
is  somewhat  rudimentary,  often  shallow  and  small,  sometimes  of 
an  oval  or  of  a  somewhat  triangular  shape.  The  acetabulum  is 
covered  with  normal  hyaline  cartilage,  the  ligamentum  teres  is 
present,  and  the  capsule  is  of  nearly  normal  structure.  At  a  later 
time,  when  the  joint  is  exposed  at  operation  at  the  age  of  five  or 
more  years,  the  capacity  of  the  rudimentary  acetabulum  may  be 
lessened  by  a  deposit  of  fat 


Fio.  321 


and  fibrous  tissue.  As  a  rule, 
however,  it  appears  to  be  of 
fair  size  and  depth.  The 
capsule  is  elongated  to  accom- 
modate the  upward  displace- 
ment of  the  femur.  It  is  hy- 
pertrophied,  especially  where 
it  covers  the  upper  part  of  the 
head  of  the  bone,  and  it  may 
be  drawn  into  a  shape  like  an 
hour-glass;  the  upper  part 
contains  the  head  of  the  bone ; 
the  anterior  wall  is  drawn 
tightly  across  the  acetabulum , 
forming  at  its  upper  border  a 
narrow  slit-like  communica- 
tion, through  which  the  liga- 
mentum teres  passes  if  it  be 
present  (Fig.  321).  The  in- 
terior of  the  capsule  is  in  part 
lined  with  synovial  membrane,  and  it  often  contains  more  synovial 
fluitl  than  is  found  in  the  normal  j(^int. 

The  ligamentum  teres,  although  probably  present  at  birtii  in 
a  large  proportion  of  the  cases,  becomes  attenuated  and  ribbon- 
like with  the  increasing  elongation  of  the  capsule,  and  after  the 
age  of  five  years,  or  at  the  time  when  the  open  operation  Ls  per- 
formed, it  is  usually  absent,  and  far  more  often  m  the  bilateral 
than  in  unilateral  cases.  According  to  I-<orenz,  in  52  cases  between 
two  and  a  half  and  five  years  it  was  present  in  17;  in  48  cases 
beyond  the  age  of  five  years  it  was  present  in  but  4.      In  rare 


Congeuital    di.slocation  of  the   hip,   showing    the 
original  and  the  acquired  acetabula.     (Lorenz.) 


518 


ORTHOPEDIC  SURGERY 


instances  it  may  be  hypertropliied.  In  my  own  experience  the 
ligament  is  present  in  a  very  much  larger  proportion  of  the  cases, 
although  it  is  often  so  rudimentary  that  it  might  easily  be  over- 
looked. 

A  shallow  secandanj  acetabulum,  formed  in  part  by  the  direct 
pressure  of  the  head  of  the  bone  through  the  adherent  capsule, 
and  in  part  the  result  of  irritation  of  the  periosteum,  is  usually 
found  upon  the  ilium  (Fig.  322),  but  it  is  not  often  of  sufficient 


Fig.   322 


Congenital  di.slocation  of  the  hip  in  adult  age,  showing  the  abnormal  shape  of  the  ace- 
tabulum, the  depressions  in  the  ilium  caused  by  the  pressure  and  friction  of  the  head  of  the 
femur,  and  the  destructive  effect  of  this  pressure  and  friction  upon  the  femur.     (Adams.) 

depth  to  assure  a  secure  support  for  the  head  of  the  femur;  thus 
its  upper  margin  gradually  recedes  or  two  distinct  depressions 
may  be  formed,  one  above  the  otlier.  The  upper  extremity  of 
the  femur  is  usually  somewhat  atrophied.  The  neck  is  often 
.shorter  than  normal,  and  its  angle  may  be  lessened,  and  in  many 
instances  its  forward  inclination  is  increased.  The  head  of  the 
bone  may  be  nearly  normal,  although  usually  it  is  somewhat 
flatt(;ned  on  its  posterior  and  under  surface,  or  it  may  be  somewhat 
conical,  acorn-lil«!  in  shape,  or  again  comj)ress(!d  from  side  to 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA       519 


side  to  an  almond  shape  or  otherwise  distorted.  The  al^nonnal- 
ities,  in  part  congenital,  become  more  marked  with  age,  and  in 
adult  specimens  the  head  and  neck  of  the  femur  may  be  so  atro- 
phied and  worn  away  as  to  present  but  little  semblance  of  normal 
contour  (Fig.  322). 

There  are  secondary  changes  in  the  bones  of  the  pelvis.     In 
unilateral  dislocation  the  pelvis  is  usually  somewhat  atrophied 


Fig.   323 


Fio.   324 


/ 


Unilateral  dislocation,  showing  the  incli- 
nation of  the  body  toward  the  shorter 
leg. 


The  same  patient  before  operation,  show- 
ing the  abnormal  lordosis  and  rotation 
of  the  pelvis.    (See  Figs.  351  and  3.')2.) 


on  the  affected  side,  and  a  lateral  inclination  of  the  spine  may  be 
present.  The  final  changes  in  the  pelvis  caused  by  the  bilateral 
dislocation  arc  more  important;  its  inclination  is  increased,  the 
lumbar  lordosis  is  exaggerated,  the  sacrum  is  forcetl  forward  and 
downward  so  that  the  anteroposterior  diameter  is  diminished ;  the 
tuberosities  of  the  ischia  are  everted  and  the  transverse  diameter 
of  both  the  inlet  and  outlet  of  the  pelvis  is  increased. 


520  ORTHOPEDIC  SURGERY 

The  long  muscles  of  the  thigh  are  shortened,  while  those  attached 
about  the  trochanter  are  changed  in  direction  and  are  usually 
lengthened.  There  is  also  a  slight  general  muscular  atrophy 
that  is  particularly  marked  in  the  gluteal  group. 

The  changes  that  have  been  described  are  in  great  degree 
secondar}^  to  the  displacement.  They  are  in  part  congenital,  in 
part  accommodative,  and  in  part  due  to  the  influences  of  attrition 
and  injury,  to  which  the  abnormal  mobility  predisposes.  Thus, 
as  a  rule,  they  become  more  marked  with  increasing  age,  and  in 
some  of  the  adult  specimens  but  little  resemblance  to  the  normal 
parts  remains. 

As  a  rule,  congenital  dislocation  of  the  hip  is  not  accompanied 
by  defective  development  or  deformity  elsewhere,  although  cases 
are  sometimes  seen  in  which  a  general  laxity  of  ligaments  is  present 
or  in  which  the  dislocation  may  be  one  of  a  series  of  deformities 
and  malformations. 

Etiology. — Nothing  positive  is  known  of  the  etiology  of  the 
dislocation.  In  a  small  proportion  of  the  unilateral  cases  it  may 
be  due  to  violence  at  birth,  but  the  fact  that  nearly  85  per  cent, 
of  the  patients  are  females  makes  it  evident  that  the  primary 
cause  can  be  neither  injury  nor  disease. 

Hereditary  influence  can  be  established  in  a  few  instances. 
The  writer  has  examined  three  female  children  in  a  family  of 
nine,  in  each  of  whom  there  was  dislocation  of  the  left  hip,  the 
order  being  the  third,  eighth,  and  ninth  child.  Also  twins  in 
another  family,  one  having  single  and  the  other  double  dislocation. 
And  in  four  instances  congenital  displacement  was  present  in  the 
mothers  of  patients.  Vogel,^  from  an  investigation  of  200  cases 
concludes  that  heredity  might  have  had  some  remote  influence 
in  30  per  cent. — viz.:  In  0  instances  the  mother  had  congenital 
(iislocation,  in  9,  the  father,  in  7  sisters  of  the  father,  in  8  sisters 
of  the  mother,  in  one,  both  father  and  mother.  In  25  per  cent, 
of  the  cases  there  had  been  breech  presentation. 

Of  the  various  theories  that  have  been  advanced  to  account  for 
the  condition,  the  most  reasonable  seems  to  be  a  predisposing 
attitude  of  flexion  and  adduction  abnormally  prolonged  in  utero. 
Dislocation  at  this  joint  is  relatively  frequent  because  the 
acetabulum  is  shallow  in  f(X'tal  life.  Acconhng  to  Sainton's 
observations,  in  new))orn  children  it  covers  but  one-third  of  the 
femur,  but  at  the  age  of  five  years  it  is  sufficiently  deep  to  contain 
on<'-lialf  of  it. 

'   JJeutMch.  Zeits.  f.  Chir.,  71.,  Bd.  iii.  uiid  iv. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA    521 


Fig.   325 


Heusner  and  Marcwald^  from  an  examination  of  eighty-five 
foetuses,  conclude  that  the  greater  liability  of  females  to  the  dislo- 
cation is  explained  by  the  disproportionate  laxity  of  the  capsule 
as    compared    with   males. 

It  is  probable  that  the  dis- 
location, in  some  cases  at 
least,  is  at  birth  a  sublux- 
ation only,  that  becomes 
complete  through  muscular 
action  and  by  the  use  of 
the  limb  in  standing  and 
walking. 

Symptoms.  —  The  dis- 
placement does  not,  as  a 
rule,  attract  attention  until 
the  child  begins  to  walk, 
although  in  some  cases  the 
mother  may  have  noticed  a 
peculiar  breadth  of  pelvis, 
or  a  "lump"  on  the  buttock, 
or  a  "snapping"  about  the 
hip-joint,  or  a  pecidiar  atti- 
tude of  the  limb  before  this 
time. 

Unilateral  Dislocation. — If 
the  displacement  is  of  one 
side,  a  limji  is  immediately 
apparent,  which  becomes 
more  noticeable  as  the  child 
grows  older.  The  limp  is 
peculiar,  and  its  character 
is  explained  by  its  cause;  for 
the  shortened  limb,  owing  to 
the  elasticity  of  the  capsule,  becomes  still  shorter  when  the  weight 
falls  upon  it;  thus  in  walking  there  is  a  peculiar  lunge  of  the  body 
toward  the  short  side,  that  has  been  likened  to  the  motion  in  walk- 
ing down  stairs.  In  the  ordinary  form  the  head  of  the  femur 
is  displaced  upward  and  backward,  and  in  compensation  the 
pelvis  is  tilted  toward  the  short  limb  and  its  inclination  is  increased; 
it  is   thus  twisted  downward  and  forward   so   that  the  anterior 


Congenital  dislocation  of  both  hips,  illustrating 
the  separation  of  the  thighs,  the  abnormal  breadth 
of  the  pelvic  region,  and  the  prominent  troclianters. 


•    Zeits.  f.  Orth.  Chir.,  1902,  Bd.  x..  If.  4. 


522  ORTHOPEDIC  SURGERY 

superior  spine  lies  at  a  lower  level  and  in  advance  of  that  of  the 
opposite  side  (Figs.  323  and  324). 

At  an  early  age  the  shortening  of  the  limb,  due  to  the  elevation 
of  the  trochanter,  is  from  one-half  to  three-quarters  of  an  inch. 
In  later  childhood  the  elevation  is  from  one  and  one-half  to  two 
inches,  and  in  adult  life  it  may  be  considerably  more. 

Fig.   326 


Bilateral  coriKonital  dislouatum  of  llie  liip,  showing  the  exaggerated  lordosis. 

The  effect  of  the  disj)lacement  is  also  shown  by  a  flattening  of 
the  buttock,  and  usually  the  elevated  and  prominent  trochanter 
may  be  seen  as  an  abnormal  lateral  projection,  on  a  level  with 
the  anterior  suj^erior  spine,  whicli  is,  as  has  been  stated,  soine- 
what  tilted  downward. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     523 

111  infancy  motion  in  the  false  joint  is  more  free  than  ntjrinal, 
and  the  abnormal  mobility  can  be  demonstrated  by  alternate 
traction  and  upward  pressure  on  the  limb,  but  as  the  femur  be- 
comes larger  and  the  upward  displacement  increases  the  mobility 
is  restricted.  The  range  of  abduction  is  much  diminished,  and 
in  extreme  cases  the  limb  may  become  permanently  adducted 
and  flexed,  thus  adding  the  apparent  shortening  of  adduction  to 
that  caused  by  the  dislocation  (Fig.  327). 

Bilateral  Dislocation. — When  the  dislocation  is  bilateral  the 
shortening  of  the  limbs  is,  as  a  rule,  equal  or  nearly  so,  and  if,  as 
is  usual,  both  femora  are  displaced  backward,  the  pelvis  is  tilted 
forward;  thus  in  compensation  "the  hollow"  of  the  back  is 
increased,  the  abdomen  protrudes,  tiie  luittccks  are  flattened,  the 

Fig.  327 


Congenital  dislocation  in  an  adolescent,  illustrating  the  flexion  contraction 
in  a  well-marked  case. 

pelvis  appears  to  be  abnormally  wide,  and  the  thighs  are  sepa- 
rated by  a  considerable  interval  (Figs.  325  and  326).  The  limp 
characteristic  of  the  single  displacement  is  replaced  by  an  exag- 
gerated waddle,  a  "sailor  gait." 

General  Symptoms. — In  early  childhood  there  are  no  special 
symptoms  other  than  the  limp  or  the  waddle,  but  as  the  child 
becomes  more  active  it  usually  complains  of  discomfort  after 
exertion.  It  is  easily  fatigued,  and  at  times  it  may  sufi'er  actual 
pain.  These  symptoms  are,  of  course,  more  marked  in  the  double 
than  in  the  single  displacement,  because  in  the  latter  case  the 
normal  limb  is  capable  of  bearing  more  than  its  share  of  the  strain. 
The  symptoms  often  increase  during  adolescence,  but  they  may 
become  less  troublesome  in  adult  life,  when  the  head  of  the  bone 
may  have  found  a  permanent  resting  place  on  the  pelvis;  a  security 


524 


OB THOPEDIC  S UBGER Y 


Fig.  328 


which  is  often  assured  bv  a  corresponding  hmitation  of  the  range 
of  motion.  The  shortening  and  the  secondary  effects  of  the  dis- 
placement, of  course,  persist,  so  that  the  individual  is,  as  com- 
pared with  the  normal  standard,  more  or  less  disabled  and  in 
certain  instances  noticeably  deformed. 

The  great  majority  of  the  patients  are  females,  and,  because 
of  the  less  laborious  occupations  and  the  dis- 
tinctive dress,  the  disability  and  its  effects  are 
less  serious  than  if  the  displacement  were 
more  equally  divided  between  the  sexes. 

Anterior  Dislocation. — The  symptoms  of  the 
unilateral  anterior  dislocation,  in  which  the 
head  of  the  bone  lies  beneath  the  anterior 
superior  spine,  are  much  less  marked  than  in 
the  ordinary  form  because  the  relation  of  the 
pelvis  to  the  femur  is  nearly  normal ;  so  that 
secondary  deformity  is  slight.  The  shortening 
is  less  and  the  limp  is  less  noticeable  because 
the  resistance  of  the  tissues  attached  to  the 
anterior  superior  spine  is  sufficient  to  assure 
a  relatively  secure  support. 

In  bilateral  anterior  dislocation  the  entire 
body  is  swayed  slightly  backward,  but  the 
lumbar  lordosis  is  not  increased;  in  fact,  the 
back  is  often  peculiarly  flat.  Otherwise  the 
symptoms  do  not  differ,  except  in  degree,  from 
those  of  the  posterior  displacement  (Fig.  328). 
Supracotyloid  Displacement. — As  has  been 
stated,  in  early  cases  the  displacement  may  be 
a  -form  of  subluxation  in  which  the  head  lies 
but  slightly  above  the  normal  position.  The 
same  upward  displacement  is  occasionally 
found  in  older  subjects.  The  physical  signs  are 
similar  to  those  of  the  anterior  displacement. 
Diagnosis. — The  diagnosis  offers  no  diffi- 
culty. Tlic  history  of  the  limp  or  waddle 
noticed  when  the  child  began  to  walk  and  yet  unaccompanied 
by  pain  or  prec^eded  by  injury  or  disease  is  in  itself  sufficiently 
distinctive.  If  the  displacement  is  of  one  side,  measurement 
demonstrates  the  shortening  as  compared  with  the  other  limb, 
a  shortening  that  is  explained  by  the  prominence  and  the  eleva- 
tion   f)f    tlie    trochanter    above    N^laton's    line.       Traction    and 


Bilateral  anterior  con- 
genital (iislooation.  The 
lordo.sin  is  far  lesH  marked 
than  in  the  ordinary  form. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     525 

upward  pressure  on  the  leg  will  demonstrate  the  abnormal 
mobility  of  the  displaced  head;  and  finally,  if  the  thigh  be  flexed 
and  adducted  to  its  extreme  limit,  the  neck  and  head  of  the  femur 
can  be  easily  distinguished  moving  under  the  gluteal  muscles 
when  the  limb  is  rotated.  Thus  it  may  be  differentiated  from 
depression  of  the  neck  of  the  femur  {coxa  vara),  in  which,  although 
the  trochanter  is  elevated,  the  neck  and  head  of  the  bone  cannot 
be  felt,  and  in  which  the  abnormal  mobility,  characteristic  of  the 

Fig.   329 


Bilateral  congenital  dislocation  of  the  hip. 

dislocation,  is  absent.  Again,  coxa  vara  is  almost  never  a  con- 
genital affection;  therefore,  the  history  itself  would  practically 
exclude  it. 

Upward  displacement  of  the  fennir  not  infrequently  follows 
infectious  epiphysitis  or  arthritis  of  infancy  or  early  childhood. 
In  such  cases  a  part  of  the  upper  extremity  of  the  bone  is  nsually 
destroyed,  so  that  the  head  cannot  be  distinguished  on  palpation. 
iVlthough  the  other  physical  signs  are  similar  to  those  of  the 
congenital  displacement,  the  scars  about  the  joint  present  the  evi- 


526 


OR THOPEDIC  S UR G ER Y 


Fig.   330 


dence  of  former  disease,  and  the  liistorv  is  almost  always  available 
for  diagnosis.  Thus,  as  a  rule,  such  disabilities,  as  well  as  trau- 
matic dislocations  or  other  results  of  injury  or  disease,  are  readily 
excluded. 

The  bilateral  dislocation  presents,  of  course,  the  same  physical 
signs  as  the  single  form;  it  is  even  more  easily  recognized  by  the 
peculiar  appearance  and  distinctive  gait  of  the   patient.      The 

waddling  gait  may  be  simulated  by 
that.of  extreme  bow-legs,  but  the  hip- 
joints  are,  in  this  deformity,  normal 
in  appearance  and  function.  The 
swagger  of  lumbar  Pott's  disease  is 
also  somewhat  similar,  but  this  is  an 
acquired  painful  disease  of  the  spine, 
in  which  the  hip-joints  are  normal  in 
appearance  and  usually  so  in  function 
Pseudohypertrophic  paralysis  may 
be  mentioned  as  causing  a  somewhat 
similar  gait  and  attitude,  but  here  the 
resemblance  ceases. 

As  has  been  stated,  the  diagnosis 
of  congenital  dislocation  can  be 
easily  made  by  physical  examina- 
tion; the  only  real  difficulty  is  ex- 
perienced in  certain  dislocations  or 
subluxations  of  the  anterior  type  and 
in  cases  seen  in  early  infancy  in  which 
the  dislocation  may  be  incomplete, 
but  opportunity  for  such  early  diag- 
nosis is  rarely  offered.  In  doubtful 
cases  a  Roentgen  picture  will  de- 
monstrate the  character  of  the  dis- 
ability (Fig.  329). 

Treatment. — Dupuytren,  in  1829, 
after  a  careful  study  of  the  anatomy 
of  the  deformity,  came  to  the  con- 
clusion that  it  was  not  only  incurable  but  that  palliation  of  its 
effects  even  was  hardly  attainable ;  and  for  sixty  years  the  state- 
ment was  generally  accef)ted,  although  cures  were  attained  in  all 
pnW)ability  by  Pravaz,  of  T^yons,  1S47,  and  at  a  much  later  time 
by  Paci,  of  Pisa,  1887. 

The  term  dislocation  natiiniilly  suggests  replacement  and  reten- 


Bilateral  dislocation  in  adolescence. 
Thi.s  patient  was  practically  disabled 
by  pain  and  weakness. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     527 

tioii  of  the  displaced  bone  in  its  proper  place,  and  in  18UU  Hoffa 
first  performed  this  operation  with  success  by  opening  the  joint 
from  behind  and  enlarging  the  rudimentary  acetabuknii  to  a  size 
sufficient  to  contain  the  head  of  the  bone.  The  details  of  the 
operation  were  afterward  modified  by  Lorenz/  and  at  the  present 
time  the  original  operation  has  been  to  a  great  extent  supplanted 
by  bloodless  reposition,  but  to  Hoffa  belongs  the  credit  for  the 
introduction  of  the  modern  treatment  of  this  disability. 

The  Lorenz  Operation  of  Bloodless  Reduction,  Retention, 
and   Weight   Bearing. 

This  treatment  is  based  on  the  experience  obtained  by  the 
open  treatment  that  an  acetabulum  of  fair  size  is  practically 
always  present.  This  acetabulum  is  not  of  sufficient  capacity  to 
retain  the  head  of  the  femur  when  the  limb  is  in  the  normal  attitude, 
but  it  is  sufficiently  deep  to  permit  of  retention  when  the  limb 
is  fixed. in  abduction. 

It  has  been  proved,  also,  that  by  traction  and  leverage  the 
head  of  the  femur  in  most  instances  may  be  forced  into  direct  con- 
tact with  the  rudimentary  acetabulum.  Once  this  contact  or 
reposition  is  attained,  the  limb  must  be  fixed  to  prevent  dis- 
placement, and  as  soon  as  possible  the  patient  must  stand  and 
walk  in  order  that  weight  and  friction  may  deepen  the  rudimen- 
tary acetabulum.  Meanwhile  the  distended  capsule  and  other 
tissues  contract  about  the  new  joint,  and  the  muscles  become 
accustomed  to  their  new  functions.  That  the  acetabulum  may 
be  actually  enlarged  by  the  presence  of  the  head  of  the  femur  is 
proved  by  the  fact  that  secondary  depressions  of  sufficient  size  to 
form  joints  of  fair  stability  are  often  found  upon  the  pelvis  in 
anatomical  specimens  from  older  subjects. 

The  Lorenz  Operation. — The  first  step  in  the  operation  is  to  over- 
come the  resistance  of  the  tissues,  namely,  of  the  capside  and  of 
the  long  muscles  that  liave  become  structurally  shortened  in 
accommodation  to  the  upward  displacement  of  the  head  of  the 
femur.  The  second  step  is  to  reduce  the  dislocation,  or  rather 
to  force  the  head  of  the  femur  over  the  posterior  or  upper  bonier 
of  the  acetabulum.  The  third  is  to  increase  the  security  of  the 
articulation  by  stretching  the  anterior  border  of  the  capsule.  The 
fourth  is  to  fix  the  parts  securely  in  a  plaster  bandage. 

'   Pathologic  und  Therapie  der  Angebornen  Hoeft.  Verrenkung,  Wien,  1S95;  Ucber  heilung 
der  Augebornen  Hoeftgelenk  Verrenkung,  Leipzig  u.  Wien,  1900. 


528 


ORTHOPEDIC  SURGERY 


The  patient  is  placed  upon  a  table  with  a  thick  folded  sheet 
beneath  the  buttocks.  The  assistant,  standing  opposite  the  oper- 
ator, fixes  the  pelvis  with  his  hands  (Fig.  331).  In  some  in- 
stances better  control  is  assured  by  pressing  the  flexed  thigh  of 
the  sound  side  downward  against  the  abdomen,  as  in  the  Thomas 
test  for  flexion  in  hip  disease. 

The  operator  first  flexes  the  thigh  to  a  right  angle  with  the 
body,  then  forcibly  abducts  it,  at  the  same  time  kneading  the 
tense  muscles  with  the  ulnar  border  of  the  hand,  stretching  and 
rupturing  the  fibres  until  the  normal  prominence  has  entirely 
tlisappeared.     The  stretching  is  continued  imtil  the  limb  can  be 


Fir,.  331 


Reduction  of  dislocation  of  t}ie  right  hip.     First  step.     The  operator  overcomes  the 
resistance  offered  by  tlie  adductors  by  forcible  massage. 

forccfl  down  to  the  jjlane  of  the  body.  One  next  overcomes  the 
shortening  of  the  tissues  on  the  posterior  aspect  by  flexing  the 
limb,  extended  at  the  knee,  upon  the  trunk,  gradually  forcing  it 
downward  until  the  toes  may  Im'  placed  against  tlie  patient's  face 
(Fig.  332).  During  this  maiujeuvre  the  assistant  fixes  the  pelvis 
by  holding  the  extended  thigh  of  the  sound  side  firmly  against  the 
table,  '{'he  next  step  is  to  overcome  the  resistance  of  the  tissues 
on  the  fnmt  of  the  joint.  Tlie  pelvis  is  fixed  by  the  assistant. 
The  leg  is  then  flexed  upon  the  thigh,  and  the  thigh  is  forced 
downward  behind  the  plane  of  the  body,  or  the  patient  may  be 
turned   upf)n   the;  side,  as   in   Fig.   333.     After  this   preliminary 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     529 


Fig.  332 


Forcilile  flexion  of  llie  extended  limb  on  tfie  abdomen.     Second  step  in  the  operation. 

Fig.   333 


Forcible  extension  of  the  thigh.     Third  .step  in  the  operation. 
34 


530  OB THOPEDIC  S  UR GEE  Y 

stretching,  traction  is  mtule  upon  the  hnib,  and  if  with  sHght 
efi'ort  the  trochanter  can  be  drawn  down  to  Nela ton's  Hne  reduc- 
tion is  attempted. 

Reduction. — The  pelvis  having  been  fixed  as  in  the  first  position, 
the  hmb  is  slowly  and  forcibly  abducted  over  a  wedge  of  wood 
suitably  padded,  the  apex  of  which  is  placed  between  the  tro- 
chanter and  the  pelvis  (Fig.  334).  As  the  limb  is  gradually 
forced  downward  to  and  behind  the  plane  of  the  body,  the  head 
of  the  femur  is  forced  upward  until  it  finally  snaps  over  the  pos- 
terior border  of  the  acetabulum.  Reduction  is  usually  accom- 
panied by  a  distinct  jar,  and  often  by  an  audible  thud.  It  is  also 
indicated  by  tension  upon  the  posterior  muscles  of  the  thigh,  which 
causes  fixed  flexion  of  the  leg.  An  effort  is  now  made  to  increase 
the  capacity  of  the  joint.     The  patient  is  turned  upon  the  sound 

Fig.   334 


Reposition.  The  thigh  is  forcibly  abducted  over  the  padded  wedge.  Fourth  step  in 
the  operation.  The  wedge  is  of  hard  wood  of  the  following  dimensions:  length,  93^  inches; 
height,  3)^  inches;  base,  3  inches. 

side  and  the  pelvis,  having  been  fixed  by  the  assistant,  the  operator 
draws  the  thigh  over  and  over  again  behind  the  plane  of  the  body, 
and  at  the  same  time  rotates  it  from  side  to  side.  The  security 
of  the  reposition  is  then  determined.  One  tests  successively 
the  stability  or  depth  of  the  superior  margin  of  the  acetabulum 
by  reducing  the  abduction;  of  the  posterior  margin  by  lifting  the 
thigh  vcntralward,  and  in  a  similar  manner  the  inferior  border. 
Upon  this  examination  the  prognosis  is  made;  if  the  stability 
allows  an  approximation  to  the  normal  position  before  displace- 
ment occurs  the  prognosis  is  good.  If,  on  the  otlier  hand,  the 
margins  of  the  acetabulum  are  so  ill-formed  that  displacement 
occurs  very  easily  the  prognosis  is  bad. 

Th(!   operation    is   varied    somewhat   in    certain    instances.     If 
alter  the  stretching  the  trochanter  still  remains  above  N(^latcn's 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     531 

line,  one  attempts  to  overcome  the  remaining  resistance  by  direct 
traction  in  the  hne  of  the  body.  Counter-resistance  is  furnished 
by  a  folded  sheet  passed  between  the  thighs  about  the  perineum, 
the  two  ends  of  which  are  tied  about  a  corner  of  the  table.  Trac- 
tion on  the  limb  is  made  by  one  or  two  assistants  while  the  operator 
supports  the  pelvis  and  presses  downward  and  inward  upon 
the  trochanter.  Occasionally  reposition  is  effected  during  this 
manoeuvre — that  is,  the  head  is  drawn  over  the  superior  instead 
of  the  posterior  l)or{Ier  of  the  acetabulum. 

i  Preliminary  Traction. — In  the  treatment  of  older  patients  or 
of  more  resistant  cases  preliminary  traction  in  bed  is  advisable. 

Fro.  335 


Reposition  in  young  subjects,  the  thumb  being  used  as  the  fulcrum  to  reduce  the  left  liip. 

The  traction  must  be  considerable,  and  heavy  weights,  if  possible 
up  to  forty  pounds  or  more;  should  be  employed  for  two  or  more 
weeks.     This  is  of  great  advantage. 

Reduction  in  Two  Sittings. — If  the  reduction  is  more  than  usually 
difficult,  rc<juiring  more  force  than  is  deemed  safe,  the  limb 
should  be  fixed  in  a  plaster  spica  in  the  attitude  of  abduction, 
the  actual  reposition  being  deferred  for  one  or  more  weeks.  At 
the  second  op(>ration  the  reduction  can  be  easily  accomplished 
in  most  instances. 

Reduction  in  Young  Subjects. — In  younger  subjects  the  wedge 
is  not    necessary,  the   thumb   of   the   operator   being  used   as  a 


532 


OETHOPEDIC  SURGERY 


fulcrum  beneath  the  trochanter  to  Hft  and  push  the  head  upward 
while  the  limb  is  abducted.  In  this  class  of  cases  much  less 
force  is  required  in  the  preliminary  stretching  (Fig.  335)  and  in 
the  treatment  of  very  young  subjects  reduction  may  often  be 
effected  by  simply  abducting  the  limb. 

After  reposition  has  been  accomplished  and  when  the  greatest 
possible  stability  is  assured  by  abducting  the  thigh  again  and 
again  and  forcibly  rotating  it  from  side  to  side  to  stretch  the  con- 
tracted anterior  wall  of  the  capsule  and  by  extending  the  leg  upon 
the  thigh,  to  thoroughly  overcome  the  resistance  of  the  hamstring 
muscles  the  plaster  bandage  is  applied.  A  close-fitting  stock- 
inette shirt,  of  which  one-half  has  been  cut  and  sewed  to  cover 
the  limb  as  a  drawer,  is  drawn  on  over  the  limb,  threaded  as  it 


Fig.    336 


The  position  in  which  tlie  limb  is  held  when  the  |)la.ster  liandat^e  i.s  ai)plied. 

were,  with  a  long  bandage,  the  "scratclu>r."  The  patient  is 
then  placed  upon  the  pelvic  rest  and  the  limb  is  held  in  the  posi- 
tion of  greatest  stability  at  a  right  angle  with  the  trunk  and 
lying  behind  the  plane  of  the  body.  The  jx^lvis  and  thigh  are 
thoroughly  and  thickly  covered  with  layers  of  sheet-wadding  or 
cotton.  Tliis  is  banchiged  firmly,  to  assure  a  slight  elastic  com- 
pression (Fig.  336). 

The  plaster  spica  is  then  applied.  This  should  be  thick  and 
firm,  at  least  a  dozen  and  oftentimes  inany  more  of  the  ordinary 
si2{e  being  used  by  Lorcuz.  These  bandages  are  drawn  snugly 
around  the  pelvis  aud  thigh  by  a  series  of  reverses  and  figure-of- 
eight   turns,   clasping   the   iliac   crests   and   thoroughly   covering 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     533 

in  the  buttock.  The  support  is  cut  away,  to  allow  motion  at  the 
knee-joint,  especial  care  being  taken  to  evert  the  edges  and  thus  to 
prevent  pressure.  The  ends  of  the  shirting  are  then  drawn 
smoothly  over  the  bandage  and  are  sewed  to  one  another  (Figs. 
337  and  338). 

The  operation  is  usually  followed  by  swelling  and  discoloration 
in  the  adductor  region  and  more  or  less  pain,  of  a  starting, 
spasmodic  character,  especially  when  the  leg  is  moved.  This  soon 
passes  away,  usually  during  the  first  or  second  week,  and  the  child 
is  then  encouraged  to  stand.  As  it  is  only  with  extreme  difficulty 
that  the  foot  on  the  operated  side  can  be  brought  to  the  floor,  a 
cork-soled  shoe  from  one  and  a  half  to  three  inches  in  heifjht  is 
usually  worn  to  facilitate  walking. 

Fig.   337 


A  plaster  bandage  applied  by  Lorenz,  illustrating  the  extreme  thickness  of  the  ijelvic 
portion  and  discoloration  of  the  adductor  region. 

As  has  been  stated,  walking  is  encouraged  on  the  theory  that 
weight  bearing  and  the  stimulation  of  functional  activity  will 
increase  the  stability  of  the  joint  by  deepening  the  acetal)ulum 
and  accentuating  its  boundaries.  In  most  instances  the  range 
of  extension  at  the  knee  is  for  a  time  somewhat  restricted.  This 
restriction  is  overcome  by  })assive  force  and  by  the  voluntary 
effort  of  the  patient.  The  first  bandage  is  allowed  to  remain  in 
place  for  from  three  to  six  months,  the  skin  being  kept  in  gootl 
condition  by  daily  vigorous  rul)bing  with  the  baud  ixMieath  the 
supporting  bandage.  In  addition  the  leg  shonld  be  regularly 
massaged;  after  a  few  weeks  the  bandage  becomes  loo.sc  about  the 
pelvis.     This  will  permit  rubbing  of  the  buttoclvs.     One  is  able 


534 


OR  THOPEDIC  S  UR  GERY 


also  by  palpation  of  the  anterior  region  to  ascertain  whether  or 
not  the  head  of  the  femur  is  in  proper  position.  In  young  children 
the  bandage  must  be  changed  as  often  as  it  becomes  offensive. 
In  from  three  to  six  months  it  may  be  supposed  that  the 
accommodative  contraction  of  the  muscles  about  the  joint  and 
of  the  capside  will   lessen  the   danger  of   redis placement.     The 


Fig.   338 


I'nilateral  coriKeiiital  dislooation,  sliowinK  the  lixatiun  liandapto.  A  shoe  with  a  cork 
.-<o1r  aVjout  two  inches  in  heiglit  slioukl  Ije  worn  on  the  operated  side,  while  the  attitude  of 
exaKKfrated  abduolioii  is  maintained. 

limb  is  then  let  down  sojnewhat  so  that  the  patient  is  able  to  walk 
about  without  the  aid  of  a  high  shoe.  The  second  bandage  is 
retained  for  three  months  or  more,  and  it  is  then  removed,  the 
period  of  retention  being  from  six  to  twelve  months,  according 
to  the  stability  of  the  joint  at  the  time  of  reduction.  In  the  treat- 
ment of  very  young  children,  when  in  testing  the  stability  at  the 
time  r)f  operation  the  femur  is  not  displaccul,  even  when  tlie  normal 


CONGENITAL  DISLOCATION  OF  HTP  AND  COXA    VARA     535 

position  is  approached,  the  limb  may  be  fixed  by  the  plaster  in 
a  less  distorted  attitude — what  Lorenz  calls  the  indifferent  position 
of  flexion,  abduction,  and  outward  rotation. 

So,  also,  when  the  tests  at  the  operation  show  fair  stability  a 
second  bandage  need  not  be  applied  after  a  preliminary  reten- 
tion of  from  six  to  nine  months,  or  even  a  much  shorter  time  if 
proper  supervision  can  be  provided,  but  it  is  better  to  err  on  the 
side  of  safety  in  the  matter  of  fixation. 

When  the  retention  bandage  is  finally  removed  the  attitude  of 
moderate  abduction  and  outward  rotation  persists  for  a  time,  in 
some  instances  for  several  months.  This  being  an  indication  of 
stability,  is  considered  a  favorable  sign,  and  no  attempt  is  made 
to  correct   it.     If,  on   the  other  hand,  as  in   the   older  class  of 

Fig.   339 


Illustrating  the  limitation  of  the  range  of  abduction  in  the  attitude  of  right  angular 
flexion  in  bilateral  dislocation.     Compare  with  Fig.  341. 


patients,  the  fixed  abduction  persists  the  patient  should  be  anaes- 
thetized and  the  contracted  tissues  carefully  stretched.  In  most 
cases  of  this  character  the  cause  of  the  distortion  is  a  jiartial 
pubic  displacement,  the  head  of  the  bone  forming  a  well-marked 
projection  beneath  the  femoral  artery.  This  projection  may  be 
reduced  by  flexing  the  limb,  and  in  certain  instances  it  may  be 
well  to  fix  the  limb  for  a  time  in  a  slightly  flexed  position  until 
the  tendency  toward  the  anterior  displacement  is  les.sened.  In 
the  after-treatment  the  limb  is  massaged,  particularly  the  posterior 
and  lateral  muscles  of  the  hip,  and  the  child  is  encouraged  to 
abduct  and  to  extend  the  thigh,  and  bearing  the  weight  on  the 
operated  limb  to  sway  the   other  limb  laterally  to  the  extreme 


536 


OR THOPEDIC  S UR GER Y 


limit.  Passive  movements  are  made,  also,  in  the  direction  of 
abduction  and  extension,  the  ability  to  reproduce  the  first  or 
operation  position  during  the  early  treatment  being  considered 
essential.  In  certain  instances  the  child  for  a  time  should  sleep 
in  this  position,  the  attitude  being  assured  by  placing  the  child 
in  a  support  of  plaster  corresponding  to  the  posterior  half  of  the 
original  spica. 

Bilateral  congenital  dislocation  is  treated  In  exactly  the  same 
way  as  the  unilateral.  Both  hips  are  operated  upon  at  one  sitting, 
and  are  fixed  in  the  typical  attitude  (Fig.  334).  Walking  is,  of 
course,  difficult,  but  the  child  is  usually  able  to  stand,  and  after 
several  months  it  is  often  able  to  get  about  on  its  feet  after  a 
fashion  (Fig.  342). 

Fig.   340 


TJie  after-treatiiieiit  folUjwiriK  t  lie  removal  of  tlie  bandage  in  a  case  of  bilateral  dislo- 
cation, illustrating  hyperextension  of  the  thighs. 


When  the  second  bandage  is  aj)plied  the  limbs  are  let  down 
somewhat,  but  the  degree  dejjends,  of  course,  on  the  initial  stability. 
The  after-treatment  is  the  same  as  for  \\u\  single  dislocation, 
except,  of  course,  that  the  subsefjuent  pei-iod  of  awkwardness  is 
much  longer.  Massage;  and  exercises  (Fig.  340)  are  far  more 
important  than  in  single  dislocation,  as  the  weakness  is  greater. 
The  primary  position  (hiring  sleep  may  be  assured  by  a  cushion 
or  roll  placed  between  the  thighs. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     537 

Prognosis. — The  Lorenz  operation  is  not  without  danger.     The 
death-rate  attributed  to  anaesthesia  is  disproportionately  large  in 

Fig.  341 


IllustratiuK  the  range  r)f  normal  abduction  of  the  thighs,  from  the  attitude  of  right 
angular  flexiou. 

Fig.   342 


The  liandage  applied  after  the  reduction  of  bilateral  dislocation,  showing  a  favorite 
method  of  progression  on  a  chair. 

the  cases  reported,  and  in  this  the  violence  of  the  ni;niij>iil;itions 
is  undoubtedly  an  important  factor. 


538  ORTHOPEDIC  SURGERY 

In  450  operations  reported  by  Lorenz  the  following  accidents 
occurred : 

Fracture  of  the  neck  of  the  femur  in 11  cases 

Fracture  of  the  pelvis  in 3     " 

Peroneal  paralysis  in 3     " 

Crural  paralysis  in 5     " 

Sciatic  paralysis  in 3     " 

In  the  last  cases  the  paralysis  persisted;  in  the  others  it  was 
temporary.  In  one  case  the  femoral  artery  was  ruptured,  the 
patient  recovering  without  ill-effect.  In  one  case  gangrene  of  the 
extremity  necessitated  amputation  at  the  hip-joint. 

It  may  be  stated,  however,  that  in  the  younger  class  of  cases 
the  operation,  if  conducted  with  reasonable  regard  to  the  resist- 
ance of  the  tissues  and  to  the  susceptibility  of  the  patient,  is  prac- 
tically free  from  danger. 

In  cases  treated  at  the  proper  age — that  is,  under  six  years  for 
bilateral  and  under  eight  for  unilateral  cases — about  50  per  cent, 
of  the  unilateral  and  25  per  cent.  (50  per  cent,  for  each  side)  of 
the  bilateral  cases  can  be  anatomically  and  functionally  cured. 
Lorenz  claims  success  in  358  of  680  cases  treated,  52.6  per  cent.^ 
Nearly  all  the  others  can  be  greatly  improved,  in  that  the  pos- 
terior displacement  may  be  converted  into  an  anterior  one.  In 
such  cases,  in  which  the  head  of  the  femur  is  forced  forward 
below  the  anterior  superior  spine,  the  static  conditions  become 
approximately  normal,  and  further  displacement  is  to  a  great 
extent  prevented  by  the  firm  tissues  attached  at  this  point.  A 
stable  articulation  is  assured  by  long  retention  of  the  limb  in  the 
position  of  abduction  and  extension  by  means  of  the  plaster 
Ijandage  and  by  exercises  and  passive  movements  after  its  removal. 

As  has  been  stated,  in  successful  cases  the  head  of  the  femur 
can  always  be  palpated  directly  beneath  the  femoral  artery.  The 
first  indication  of  failure  is  a  slight  lateral  displacement  of  the  head 
to  the  outer  side  of  the  artery.  This  may  appear  even  during 
the  period  of  fixation,  and  cases  should  be  systematically  examined 
for  such  failure  by  palpating  the  head  of  the  femur  beneath  the 
bandage;  usually,  however,  it  is  not  ap})arent  until  the  ])laster 
bandage  is  removed.  At  first  there  is  no  shortening,  but  slowly, 
as  the  displacement  increases  and  as  the  head  of  the  bone  ascends 
from  the  neighborhood  of  th(!  acetabulum  to  that  beside  or  above 
the  anterior  inferior  jx'lvic  spin(>,  this  Ix-coines  evident.  At  first 
it  is  half  an  indi,  later  an  inch,  bnt  it  is  not  often  more  tlian  this, 
at  least  (hiring  elilMliood. 

'   Aiii(?ric;in  Mciliciiii!,  .Jiiiu^  IS,  1904. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     539 


Fig.   343 


It  has  been  stated  that  this  outcome  may  be  expected  in  al^jut 
half  of  the  favorable  cases  as  to  age  in  which  all  the  details  of 
the  operation  have  been  properly  carried  out,  and  it  is  the  usual 
result  in  the  unfavorable  class.  This  result,  which  is  not  classed 
by  Lorenz  as  a  failure,  but  rather  as  an  improvement,  may  be 
explained  in  certain  instances  by 
interposition  of  a  fold  of  capsule  be- 
tween the  head  of  the  bone  and  the 
acetabulum,  or  by  failure  of  the  pro- 
cess of  reformation  of  the  acetabu- 
lum. In  many  cases,  however,  it  is 
accounted  for  by  an  anterior  twist 
of  the  upper  extremity  of  the  femur, 
so  that  the  neck  instead  of  pointing- 
inward  and  slightly  forward  from  the 
shaft  is  turned  forward  and  slightly 
inward.  Thus,  in  order  to  replace 
the  head  in  the  acetabulum,  the  limb 
must  be  rotated  inward  until  the  foot 
points  inward  rather  than  forward. 

Occasionally  the  presence  of  this 
deformity  may  be  ascertained  before 
operation.  It  may  be  suspected,  for 
example,  in  nearly  all  the  anterior 
and  supracotyloid  displacements  in 
older  subjects,  and  it  could  be  de- 
monstrated, doubtless,  by  a  series  of 
Roentgen  pictures.  In  most  cases, 
however,  the  failure  of  treatment  calls 
attention  to  the  prol)able  existence  of 
.  the  deformity.  It  is,  of  course,  ap- 
parent that  the  only  remedy  is  a  cut- 
ting operation.  Ixirenz  is  content  in 
these  cases  with  anterior  apposition, 
but  if  it  is  probable  that  a  twist  in 
the  upper  extremity  of  the  femur  is 
alone  responsible  for  failure,  it  seems 
more  reasonable  to  remove  this  by 
osteotomy.  This  operation  will  be  described  in  connection  with 
the  open  operation. 

The  Treatment  of  Older  Subjects. — It  has  been  stated  that  the 
final  result  in  a  very  large  projiorticm  of  the  operations  was  anterior 


The  cure  of  cougeiiital  di^lMi-iu  ion. 
The  same  patient  is  slmwn  in  l'"ig. 
338. 


540  OR  THOPEDIC  S  UR  GER  Y 

transposition  or  apposition,  as  Lorenz  calls  it,  and  that  in  cases 
beyond  the  age  of  eight  years  this  resnlt  is  to  be  expected.  In 
this  class  of  cases — ^from  ten  to  twenty-one  years  of  age— it  is 
the  primary  aim  of  the  operation.  x\fter  preliminary  traction  in 
bed  and  after  subcutaneous  division  of  the  more  resistant  tendons 
if  this  is  necessary,  the  limb  is  forced  into  moderate  abduction 
and  extreme  extension,  so  that  the  head  of  the  bone  is  displaced 
forward  to  the  neighborhood  of  the  anterior  inferior  spinous 
process.  In  this  attitude  the  limb  is  retained  for  many  months 
by  means  of  the  plaster  bandage,  and  it  is  assured  in  the  after- 
treatment  by  the  manipulation  and  exercises  already  described. 
Although  even  in  the  most  successful  cases  a  limp  persists,  yet  it 
is  far  less  noticeable  than  in  untreated  cases,  the  discomfort  is 
relieved,  the  limb  is  lengthened,  and  the  danger  of  future  disa- 
bility is  much  lessened. 

In  those  nnusual  cases  in  which  the  adduction  and  flexion 
deformity  is  extreme,  osteotomy  of  the  femur  may  be  required, 
and  if  the  pain  is  persistent  excision  of  the  hip  may  be  necessary. 

The  Treatment  of  Congenital  Dislocation  in  Infancy. — At  the 
present  time  in  contrast  to  former  years  one  often  has  the  oppor- 
tunity to  treat  congenital  dislocation  in  infancy  and  early  child- 
hood. The  details  of  treatment  do  not  differ  essentially  from 
those  already  described,  except,  of  course,  that  reduction  is  easily 
effected  (Fig.  335)  and  that  walking  or  weighting  (functional  use 
in  other  words)  cannot  always  be  utilized  at  once  in  the  after- 
treatment.  In  this  class  of  cases,  provided  the  test  of  the  sta- 
bility of  the  joint  is  satisfactory,  one  need  not  fix  the  limb  in  the 
extreme  position.  It  is  well,  however,  to  carry  the  bandage  below 
the  knee  in  order  to  assure  for  a  time  more  complete  fixation. 
The  support  must  be  renewed  whenever  sanitary  reasons  indicate 
the  necessity.  In  many  instances  cure  is  practically  assured  in  a 
few  months. 

Variations  in  the  Treatment. — It  has  been  stated  that  the  first 
indication  of  failure  was  ordinarily  a  slight  lateral  displacement 
of  the  head  to  the  outer  side  of  the  femoral  artery,  and  that  this 
displacement  was  favored  by  the  aiiteversion  of  the  neck  of  the 
femur.  As  is  well  known,  anteversion  of  moderate  degree  is  not 
unusual  in  the  femora  of  apparently  normal  joints.  In  such 
instances  subluxation  is  j^revented  by  the  cotyloid  cartilage,  and 
by  the  normal  capsule,  both  of  which  are  deficient  in  the  congenital 
dislocation.  Wh(;n,  ther(;fore,  anteversion  is  suspected  oris  known 
to   exist,  or  if    displacement    has  recurred    after    the   operation. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     541 

it  is  well  to  rotate  the  thigli  inward,  so  that  tlie  head  of  the 
femur  Hes  sHghtly  to  the  inner  side  of  the  artery,  and  to  fix  it 
in  this  attitude  })y  extending  the  plaster  bandage  below  the  knee, 
the  leg  being  slightly  flexed  upon  the  thigh.  This  attitude  should 
be  retained  until  it  may  be  assumed  that  the  capsule  is  sufficiently 
contracted  to  restrain  the  femur  from  reluxation. 

Fig.   344 


Axillary  abduction. 


In  some  instances,  especially  in  anterior  displacement  in  young 
subjects,  the  upper  anterior  border  of  the  acetabulum  seems  to  oiler 
no  resistance  to  redisplacement.  One  may  then  place  the  limb 
in  axillary  abduction  (Werndorft"),  Fig.  344,  for  a  month  or  more, 
in  the  hope  that  the  upper  border  of  the  capsule  will  contract 
sufficiently  to  prevent  redisplacement. 

In  such  cases,  and  in  fact  in  all  cases  in  which  the  upward 
displacement  is  feared,  the  patient  should  be  anaesthetized  when 


542 


OE  THOPEDIC  S  UR  GERY 


the  plaster  is  changed.  One  may  then  hold  the  head  of  the  femur 
in  place  and  stretch  the  contracted  tissues,  particularly  the  ilio- 
femoral ligament,  sufficiently  to  permit  the  lessened  abduction,  for 
the  resistance  of  these  tissues  seems  in  certain  instances  to  be  the 
direct  cause  of  displacement. 

Arthrotomy.— If  the  Lorenz  operation  has  failed  when  all  the 
details  have  been  thoroughly  carried  out,  the  advisability  of  an 


Fig.   345 


Fig.   346 


-S'W 


/ 


'^^. 


Hilateral  dislocation  six  months 
after  rer)lacement  by  the  open 
method  in  1897,  illustrating  the 
ehangein  thecoiilour  of  tlie  trunk. 


A  successful  result  after  the  open  operation, 
illustrating  a  form  of  brace  to  be  used  in 
the  after-treatment  to  hold  the  limb  in  proper 
position   if  it  has  a  tendency  to  rotate  outward. 

exploratory  operation  suggests  itself.  Under  proper  aseptic  pre- 
cautioas  this  should  entail  no  danger  nor  should  it  compromise 
the  functional  ability  of  the  joint.  One  can  then  assure  one's 
self  tiiat  the  head  of  the  bone  is  actually  replaced  within  the 
acetabuliiMi.  Arthrotomy  is  indicated  also  if  the  resistance  to 
rei)osition  by  the  ordinary  method  is  so  great  that  dangerous 
force  must  be  exerted  to  (overcome  it. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     543 

The  joint  is  exposed  by  a  lateral  incision  about  three  inches  in 
length,  extending  downward  from  a  point  about  three-cjuarters 
of  an  inch  to  the  outer  side  of  the  anterior  superior  spine  of  the 
ilium,  the  fascia  is  divided,  and  the  line  of  junction  between  the 
tensor  vagina;  femoris  and  the  gluteus  medius  muscles  is  founrl. 
These  muscles  are  then  separated  and  are  drawn  to  either  side  by 
retractors,  thus  exposing  the  capsule  of  the  joint.  This  is  opened 
by  an  incision  parallel  to  the  neck  of  the  bone.  The  finger  is 
then  passed  through  the  opening,  down  upon  the  rudimentary 
acetabulum.  A  strong  cervix  dilator  is  next  inserted  and  the 
contracted  capsule  is  thoroughly  stretched.  If  the  ligamentum 
teres  is  present  it  is  removed. 

The  head  is  then  replaced;  the  capsule  and  overlying  tissues 
are  united  with  catgut  sutures.  The 'limb  is  then  fixed  in  the 
typical  position  by  the  Lorenz  spica.  In  the  majority  of  cases 
the  cause  of  the  failure  of  the  primary  operation  is  an  antever- 
sion  of  the  neck  of  the  femur.  In  this  event  after  replacement 
the  limb  must  be  rotated  inward  to  the  required  degree  and  fixed 
by  a  plaster  bandage  extending  below  the  knee  as  a  preliminary 
to  osteotomy. 

Osteotomy. 

When  the  limb  has  been  fixed  for  several  months  in  the  attitude 
of  inward  rotation,  so  that  stability  is  in  some  degree  assured, 
the  operation  for  correcting  the  anterior  twist  of  the  uiiper 
extremity  of  the  femur  shoidd  be  performed. 

The  plaster  bandage  having  been  removed,  a  long  drill  should 
be  pushed  through  the  trochanter  and  into  the  neck  of  the  bone 
to  fix  the  upper  fragment.  A  subcutaneous  osteotome  is  then  in- 
serted at  a  point  just  below  the  trochanter  minor  or  at  the  lower 
third  of  the  femur,  and  a  thorough  division  of  the  bone  is  made. 
The  lower  osteotomy  is  perhaps  to  be  preferred,  because  one  has 
better  control  of  the  fragments  at  this  point.  Wlien  the  division, 
is  complete,  the  upper  fragment  being  fixed  by  the  drill,  the  limb 
is  rotated  outward  until  the  normal  relation  between  the  shaft 
and  the  neck  is  restored.  A  plaster  spica  including  the  foot. is 
then  applied,  by  which  the  drill  and  the  upper  fragment  art^  fixed 
in  proper  relation  to  the  shaft.  Several  weeks  later,  when  the 
improved  position  is  assured,  this  is  withdrawn.  The  after-treat- 
ment is  the  same  as  in  the  uncomplicated  cases. 


544 


ORTHOPEDIC  SURGERY 


The  Open  Operation  with  Enlargement  of  the  Acetabulum. — The 
original  Hoft'a-Lorenz  operation,  once  the  treatment  of  routine, 
is  now  reserved  for  a  restricted  class  of  cases  in  which  the  blood- 
less operation  has  failed,  or  in  which  on  opening  the  joint  the 
acetabulum  is  found  to  be  notably  deficient. 

Supposing  the  shortening  of  the  limb  to  have  been  overcome 
bv  previous  treatment,  the  joint  and  capsule  are  opened  in  the 
manner  already  described.  One  finger  is  then  inserted  to  the 
acetabulum  and  by  its  side  a  strong,  sharp  bayonet-shaped  spoon 

Fig.    347 


Scoop.s  u.seil  in  tlic  tieul iiieiil  of  congenital  ilislocation,  also  the  subcutaneous  osteotome. 


(Fig.  347)  is  passed,  and  with  it  the  shallow  acetabulum  is  en- 
larged to  a  sufficient  size,  care  being  taken  to  accentuate  its  supe- 
rior and  posterior  border.  The  head  is  then  placed  within  it,  and 
the  wound  is  closed  or  packed  according  to  the  custom  of  the  opera- 
tor. Hoffa,  who  is  now  the  principal  exponent  of  the  operation, 
makes  an  oblique  incision  from  the  anterior  superior  spine  down- 
ward and  backward  over  the  trochanter  and  exposes  the  joint 
between  the  gluteus  niedius  and  mininuis  muscles.  He  usually 
employes  the  J3oyen  instrument  and  1) ores  out  a  very  capacious 
acetabulum.     A  long  plaster  spica  is  then  applied  with  the  limb 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA  VA RA      545 

in  an  attitiule  of  moderate  abduction  and  extension.     In  a  month, 
or  when  repair  is  complete,  a  short  I^renzspica  is  applied  and  the 

Fig.   348 


Unsuccessful  treatinciit  by  forcible  correction  (Ijorcnz  operation).     The  posterior  has 
been  cliaii.i;ed  tu  an  anterior  displacement.   Rear  view. 

patient  is  encouraged  to  walk  about.  This  su{)port  should  be  worn 
for  from  six  months  to  a  year  in  order  to  prevent  the  contractions 
that  almost  inevitably  follow  operations  of  this  character.     Exer- 

35 


546  OB  TH  OPE  DIG  SURGERY 

cise  and  forcible  manipulation  within  a  few  weeks  after  the  opera- 
tion, as  recommended  bv  many  writers,  are  not  only  of  no  service, 
but  in  the  author's  experience,  harmful. 

AMien  the  spica  is  removed  and  the  patient  is  allowed  to  run 
about,  motion  usually  returns.  At  this  time  massage  should  be 
employed  and  passive  movements  always  in  extension  and  abduc- 
tion. Later  gymnastic  training  is  of  great  value.  After  this 
operation,  provided  there  is  true  anatomical  cure,  motion  is 
usually  restricted  to  a  greater  or  less  degree,  and  in  older  sub- 
jects there  is  often  fibrous  anchylosis.  For  this  reason  it  should 
be  limited  to  unilateral  cases,  or,  at  all  events,  one  should  never 
operate  on  the  second  hip  until  the  result  of  the  operation  in 
the  first  is  known.  In  unilateral  cases  anchylosis  without  de- 
formity is  not  a  serious  functional  disability,  as  there  is  solid 
support  without  shortening;  while  if  fair  motion  is  obtained,  as  in 
many  instances,  the  functional  result  is  far  better  than  after  simple 
transposition.  It  should  be  stated  that  even  after  the  open  opera- 
tion this  transposition  is  often  the  outcome.  In  such  cases  motion 
is,  of  course,  free  and  the  stability  is  somewhat  greater  than  after 
the  bloodless  operation.  If  after  this  operation  motion  is  extremely 
limited  one  must  expect  flexion  and  adduction  deformity  unless 
it  be  prevented  by  careful  treatment.  In  certain  instances  the 
range  of  motion  may  be  increased  by  breaking  up  adhesions  and 
stretching  the  contracted  parts  under  anaesthesia. 

The  danger  of  the  operation  is  slight,  and  the  deaths,  with 
but  few  exceptions,  have  been  due  to  infection.  Lorenz  and 
HofFa  lost  several  of  their  earlier  patients  from  this  cause,  but 
with  improved  technique  the  danger  is  slight.^  The  bad  results 
of  the  operation  may,  as  a  rule,  be  accounted  for  by  its  improper 
performance,  particularly  the  failure  to  replace  the  femur  securely, 
or  by  failure  to  ensure  asepsis,  or  by  inefficient  supervision  and 
after-treatment. 

It  is  perhaps  unnecessary  to  state  that  o])erations  of  this  char- 
acter should  not  l)e  jjcrformed  unless  asepsis  can  be  assured, 
unless  the  operator  is  familiar  with  the  anatomy  of  the  parts, 
and  unless  the  essential  after-treatment  can  be  provided. 

Review  of  the  Treatment  of  Congenital  Dislocation  of  the  Hip. — 
The  j;rospcct  of  success  in  treatment  stands  in  direct  relation 
to  the  age  of  tin;  patient,  since  the  degree  of  tiie  pathological 

•  Hijffa  has  performed  the  operation  248  times,  with  10  de.atlis,  S  due  io  the  opera- 
tion, the  laHt  132  operations  without  a  dejilh.  Lorenz,  in  200  operatioiiw,  lost  4  patients 
from  septicajmia. — Ilcport  of  the  'I  liii  toonl  h  Internal  ional  Oingress,  Paris,  August,  1900. 


CONGENITAL  DliiLOCATION  OF  HIP  AND  COXA    VARA     547 

changes,  that  make  cure  difficult  or  impossible,  depends  in  great 
degree,  as  in  acquired  dislocations,  upon  the  duration  of  the  dis- 
ability. Consequently,  treatment  should  be  applied  as  soon  as 
the  displacement  is  discovered,  and,  as  has  been  stated,  there  Ls 
little  excuse  for  not  making  the  correct  diagnosis  when  the  child 


FiG.1349 


Tic.  350 


"t    ;^ 


UiiiliiU'ral  (lislociidoii.  Two  years 
after  operation  in  1897  by  the  Loreiiz 
method.     A  complete  cure. 


Unilaleriil  dislocation.  Eighteen  niontlis  after 
operation  by  the  Lorenz  method  in  1897.  A 
complete  cure. 


begins  to  walk.  The  treatment  of  selection  is  the  functional 
weighting  methotl  of  I^orenz,  modified  somewhat  in  certain  cases 
in  that  the  limb  may  be  placed  with  advantage  in  that  position 
which  best  assures  stability.  By  this  treatment  a  larger  proportion 
of  the  cases  may  be  cured,  and  in  all  instances  the  posterior  may 
be  changed  into  an  anterior  displacement,  which  is  a  great  improve- 


648 


ORTHOPEDIC  SURGEEY 


ment.  The  treatment  at  the  hands  of  a  competent  surgeon  in 
properly  selected  cases  is  free  from  danger,  for  now  that  the  stram 
that  the  tissues  will  safely  withstand  is  better  known,  violent  and 
prolonged  manipulation  has  been  discarded.  In  the  older  class,  or 
when  reduction  is  difficult,  the  resistant  parts  should  be  stretched 
by  preliminary  traction  in  bed,  or  the  reduction  should  be  accom- 
panied at  two  sittings. 


Fig.  3.51 


Fig.   352 


■) 


I.'iiilateral  dislocation,  after  operation 
by  the  Lorenz  method  in  1897.  A  com- 
plete cure.     Com|)are  with  FIr.  .323. 


Unilateral  ilislocat ion,  two  years  after 
operation.     Conii)are  with  Fig.  324. 


If  one  is  iKjt  content  with  functional  improvement  in  the  cases 
ill  which  anatomical  cure  has  not  been  attained  the  treatment 
may  be  supplemented  by  arthrotomy,  and  if  anteversion  of  the 
upper  extremity  of  the  femur  prevents  success  it  may  be  remedied 
by  osteotomy. 

Excavation  ol"  the  acetabulum  will  often  assure  anatomical 
success. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     549 

Anatomical  reposition  with  fair  or  even  very  limited  motion 
assures  better  function  in  unilateral  cases  than  transposition,  but 
anchylosis  with  deformity  is  certainly  no  improvement  on  the 
original  condition.  It  may  be  suggested,  also,  that  the  dangers 
of  open  operation  even  if  slight  must  be  considered. 

In  the  treatment  of  adolescent  cases  one  should  attempt  to 
obtain  anterior  transposition  and  to  assure  it  by  fixing  the  limb 
for  a  sufficient  time  in  the  improved  position. 

Palliative  Treatment. — Palliative  treatment  does  not  require 
extended  comment.  In  brief,  in  unilateral  cases  a  cork  sole  may 
be  worn  to  equalize  the  length  of  the  limbs,  and  in  bilateral  cases 
a  corset  suitably  strengthened  with  steel  supports  may  be  adjusted 
if  the  lordosis  is  extreme.  Exercise  and  passive  manipulation 
with  the  aim  of  retaining,  as  far  as  possible,  the  ability  to  abduct 
and  to  extend  th  ethighs  may  be  of  service  in  preventing  secondary 
contractions.  Overexertion  that  causes  discomfort  or  pain  should 
be  avoided. 

Congenital  Subluxation  of  the  Hip. 

As  has  been  stated,  there  are  cases  of  congenital  displacement 
of  the  hip  which  are  in  reality  subluxations.  In  such  cases  there 
is  a  slight  limp  and  slight  shortening,  and  an  a"-ray  picture  shows 
a  secure  acetabulum  somewhat  above  the  plane  of  the  opposite 
side.  These  subluxations  are  always  of  the  anterior  variety. 
They  should  be  treated  in  the  ordinary  manner. 

Snapping  Hip. 

Some  individuals  possess  the  power  of  slightly  displacing  the 
hip,  usually  upon  the  superior  or  upper  border  of  the  acetabulum. 
This  is  sometimes  seen  in  infancy,  the  child's  thigh  snapping  with 
a  jar  or  even  audible  sound  upward  and  downward.  This  is 
usually  accomplished  when  the  child  is  seated  in  the  mother's 
lap,  the  thigh  being  flexed  and  adducted,  and  in  this  class  of 
eases  it  is,  according  to  the  mothers,  an  evidence  of  temper.  As 
the  displacement  may  be  increased  by  habit,  it  is  well  to  restrain 
it  by  applying  a  bandage  about  the  hip  to  prevent  flexion  of 
the  limb,  which  is  apparently  preliminary  to  its  accomplishment. 
(See  Snapping  Knee.)  Snapping  about  the  hip  in  older  subjects 
is  usually  induced  by  friction  between  the  glutens  inaxinnis 
nuiscle  and  the  trochanter. 


550  ORTHOPEDIC  S UB GER Y 


Coxa  Vara. 


Synon3rms. — Depression  or  incurvation  of  the  neck  of  the 
femur;  bending  of  the  neck  of  the  femur. 

The  character  of  this  deformity  is  indicated  by  the  synonyms. 
The  term  coxa  vara  signifies  that  its  causes  and  effects  are  similar 
to  those  of  genu  valgum  and  varinn,  the  more  common  distor- 
tions of  the  lower  extremities. 

Genu  valgum  and  varum  are  common  in  childhood,  but  rarely 
develop  in  adolescence.  Coxa  vara  is,  in  comparison,  an  infre- 
c{uent  deformity,  and  it  is  peculiar  in  that  it  more  often  appears 
in  later  childhood  or  adolescence  than  at  the  earlier  period,  doubt- 
less because  the  neck  of  the  femur  is,  at  the  age  when  rhachitic 
distortions  are  common,  very  short,  and,  therefore,  relatively 
stronger  than  the  shaft,  while  in  adolescence  the  conditions  may 
be  reversed. 

The  distortions  at  the  knee  are  self-evident,  but  the  neck  of 
the  femur  is  concealed  from  view;  thus  the  diagnosis  of  coxa 
vara  may  be  somewhat  difficult;  and,  in  fact,  it  is  only  in  very 
recent  years  that  its  symptoms  have  been  recognized.  Fiorani^ 
first  described  the  deformity  as  it  had  been  observed  by  him  in 
children;  but  E.  IMiiller^  first  called  attention  to  the  affection  as 
one  of  the  deformities  of  adolescence,  which,  until  that  time,  had 
been  mistaken  for  hip  disease. 

Pathology. — The  term  coxa  vara  should  not  be  applied  to 
depression  of  the  neck  of  the  femur  that  may  be  secondary  to 
destructive  disease,  for  example,  to  osteomyelitis,  arthritis  de- 
formans, osteomalacia,  and  the  like,  but  it  should  be  reserved 
for  cases  of  simple  local  deformity.  In  most  instances  the  defor- 
mity affects  the  neck  as  a  whole  (cervical  coxa  vara);  in  others 
it  is  most  marked  at  the  epiphyseal  junction  (epiphyseal  coxa 
vara).  Epiphyseal  coxa  vara  is  more  often  found  in  the  adoles- 
cent class,  and  particularly  in  those  cases  in  which  the  symptoms 
have  been  induced  or  aggravated  by  injury  or  strain.  Whether 
the  injury  caused  primarily  a  partial  epiphyseal  separation  which 
afterward  slowly  increased  under  the  strain  of  functional  use;  or 
suddenly  increased  a  pre-existing  distortion  of  the  weakened 
part  is  sometimes  difficult  to  decide.  A  number  of  specimens 
of  coxa  vara  have  been  examined,  but  no  changes,  other  than 
such  as  might  be  caused  by  the  deformity  itself,  have  been  found. 

1  GazetU  (leiili  Ospitalc,  1881,  Noh.  10,  17. 
-  Beitruge  zur  kliri.  Ohir.,  1889,  Bd.  iv. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     55 1 


Fig.  353 


These  are,  in  brief,  congestion  and  softening  of  the  Ijone,  and 
evidences  of  irritation  within  the  joint  during  the  progressive 
stage  of  the  deformity,  with  the  general  adaptive  changes  in  all 
the  components  of  the  joint  that  always  accompany  displacement 
or  distortion.  These  may  be  considerable,  including,  in  advanced 
cases,  a  change  in  the  acetabulum,  whose  upper  border  is  less 
sharply  defined  than  normal. 

Etiology. — Many  writers  assume  that  the  weakness  of  the  neck 
of  the  femur  that  predisposes  to  deformity  is  the  result  of  local 
disease,  such  as  so-called  local 
rickets  or  local  osteomalacia. 
This  is,  however,  simply  a  con- 
venient hypothesis.  Others 
believe  the  deformity  to  be 
symptomatic  of  late  rickets, 
although  evidence  of  general 
rhachitis  is  almost  never  pres- 
ent in  the  ordinary  type  as  it 
appears  in  later  childhood  and 
adolescence. 

Coxa  vara,  at  least  of  the 
ordinary  type,  may  be  classed 
as  one  of  the  group  of  static 
deformities  of  the  lo"^er  ex- 
tremity caused  by  a  dispropor- 
tion between  the  strength  of 
the  supporting  structure  and 
the  burden  that  is  put  upon  it. 
The  support  may  be  dispro- 
portionately weak,  because  of 
inherited  delicacy  of  structure; 
it  may  be  weakened  by  injury 
or  by  disease,  or  it  may  be  over- 
burdened by  weight  or  sti'ain. 

Mechanical  Predisposition  to  Deformity. — In  many  cases  tiie  pre- 
disposition to  deformity  is  the  result  of  a  lessened  angle  of  the 
femoral  neck.  This  slight  and  predisposing  depression,  which 
appears  to  be,  in  many  instances,  the  effect  of  early  rhachids, 
becomes  exaggerated  to  deformity  during  later  childhood  or 
adolescence.  In  this  sense — that  of  a  remote  result — coxa  vara 
may  be  classed  as  one  of  the  rhachitic  deformities.     The  iinj^or- 


Section  of  the  upper  extremity  of  a  norma 
femur  at  eight  years  of  age;  angle  formed  by 
the  neck  with  the  shaft  140  ilegrees.  In  the 
normal  subject  the  neck  of  the  femur  projects 
slightly  forward  (12  degrees)  and  upward  to 
form  an  angle  with  the  shaft  of  about  125 
degrees.  In  chiklhood  this  angle  it  usually 
somewhat  greater,  and  in  later  years  it  may  be 
somewhat  less  than  125  degrees;  in  fact,  a 
variation  between  110  and  140  degrees  may  be 
within  the  normal  limit.' 


'  Humphrey,  Jour.  Anat.  Phys.,  vol.  xxiii.  p.  230. 


552  ORTHOPEDIC  SURGERY 

tance  of  this  mechanical  factor  in  the  etiology  was  demonstrated 
to  me  bv  the  investigation  of  a  number  of  cases  of  simple  frac- 
ture of  the  neck  of  the  femur  in  childhood.  In  these  cases  the 
neck  of  the  femur  was,  by  the  original  injury,  somewhat  depressed, 
and  although  immediate  functional  recovery  followed,  yet  in  a 
number  of  the  eases  progressive  deformity,  attended  by  the  symp- 
toms of  typical  coxa  vara,  resulted.  This  could  be  explained 
only  on  the  theory  that  the  lessened  angle,  subjecting  the  part  to 
greater  strain,  was  the  predisposing  cause  of  the  later  disability. 
Other  factors  in  the  etiology  may  be  general  weakness,  incident 
to  rapid  gro^^•th,  direct  injury  (fracture),  and  the  strain  of  occu- 
pation.^ 

1  this  connection  it  may  be  stated  that  fracture  of  the  neck 
of  the  femur  in  childhood  may  cause  a  deformity  which  in  the 
absence  of  a  history  could  not  be  distinguished  from  the  ordinary 
form  of  coxa  vara,  of  which,  in  fact,  it  is  the  traumatic  form. 
(See  Fracture  of  the  Neck  of  the  Femur  and  Epiphyseal  Sepa- 
ration.) 

If  the  statistics  are  limited  to  the  class  in  which  the  deformity 
causes  distinct  symptoms  it  will  appear  very  decidedly  as  an 
affection  of  late  childhood  and  adolescence.  It  is  far  more  com- 
mon in  males  than  in  females  and  it  is  usually  unilateral,  facts  that 
would  seem  to  indicate  the  influence  of  strain  or  injury  in  inducing 
or  increasing  the  distortion. 

The  points  of  special  interest  in  72  personal  cases  may  be  sum- 
marized as  follows:  In  about  one-third  of  the  cases  there  was  a 
distinct  history  of  rhachitis  in  infancy.  The  ages  of  the  patients 
were  as  follows: 

Adiilf  scents,  twelve  to  seventeen 40 

La' er  childhood,  five  to  eleven 23 

Early  childhood,  less  than  five 3 

Over  seventeen  years 6 

Total 72 

In  many  instances  the  symptoms  had  persisted  for  a  long  time, 
even  many  years,  before  the  patients  came  under  observation; 
but  taking  this  fact  into  account  it  may  be  stated  that  in  more 
than  half  the  cases  the  deformity  did  not  appear  until  adolescence 
and  that  at  least  tli roc-fourths  of  the  patients  were  beyond  the  period 
of  early  ciiildliood  when  tiie  ordinary  rhachitic  distortions  of  the 

'  Several  cases  of  coriKcnital  coxa  vara  have  Ijoen  reported.  In  siicli  instances  the 
deformity  is  often  one  of  many  fiistortions.  JJeiJression  of  the  nock  of  the  femur  in  con- 
genital disjor'ation  of  the  liip  has  been  mcritione<l  in  the  section  on  that  affection. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA      553 

limbs  are  most  common.  46  of  the  patients  were  males,  26  were 
females.  In  59  cases  the  deformity  was  unilateral,  32  of  the  right 
and  27  of  the  left  side;  in  13  it  was  bilateral.  In  the  majority  of  the 
cases  the  neck  of  the  femur  was  distorted  in  a  direction  backward 
and  downward ;  in  perhaps  10  either  directly  downward  or  down- 
ward and  forward.  Many  of  the  patients  were  observed  before 
the  rr-ray  was  available  for  diagnosis,  but  it  is  estimated  that  in 
about  one-fourth  of  the  adolescent  cases  the  distortion  was  greatest 
in  the  vicinity  of  the  head  of  the  bone  (epiphyseal  coxa  vara);  in 
the  others  the  neck  of  the  femur  as  a  whole  was  involved  (cervical 
coxa  vara). 

Symptoms.  1.  Mechanical  Effects.— The  character  of  the 
symptoms  may  be  explained  by  a  description  of  the  distortion  and 
of  its  direct  effects  upon  the  function  of  the  joint.  When  the 
neck  of  the  femur  is  depressed,  for  example,  to  a  right  angle  with 
the  shaft,  the  trochanter  is  elevated  to  a  corresponding  degree 
above  Nelaton's  line,  and  forms  a  noticeable  projection  as  con- 
trasted with  the  normal  contour  (Fig.  357),  a  projection  that 
becomes  more  marked  when  the  thigh  is  flexed  and  adducted 
(Fig.  356).  In  most  instances  the  neck  is  displaced  backward 
as  well  as  downward,  following  the  line  of  least  resistance,  and 
as  the  head  of  the  bone  remains  in  the  acetabuliun  the  trochanter 
is  thrown  forward  and  the  limb  is  rotated  outward.  The  ability 
to  abduct  the  thigh  is  dependent  upon  the  upward  inclination  of 
the  femoral  neck  (Fig.  195);  when,  therefore  this  inclination  is 
diminished  the  range  of  abduction  is  lessened,  in  part  by  the 
greater  tension  that  is  exerted  upon  the  lower  portion  of  the  cap- 
sule, in  part  by  the  direct  contact  of  the  rim  of  the  acetabulum 
with  the  neck  and  trochanter  (Fig.  354),  and  in  part  by  the  adap- 
tive contractions  that  always  accompany  distortions  of  this 
character.  It  is  evident,  also,  that  the  deformity  of  the  neck 
backward  and  downward  changes  the  relation  of  the  acetabulum 
to  the  head  of  the  femur,  so  that  abduction  or  flexion  tends  to 
displace  it  from  its  socket.  Thus  the  range  of  abduction,  of 
inward  rotation,  and  of  flexion  is  limited,  while  that  of  atlduction, 
outward  rotation,  and  extension  may  be  increased. 

There  is  actual  shortening  of  the  limb  dependent  upon  the 
upward  displacement  of  the  shaft  of  the  femur.  This  is  not  often 
more  than  an  inch  in  the  ordinary  type  of  adolescent  deformity, 
but  the  apparent  shortening,  caused  by  the  adduction  and  the 
accommodative  upward  tilting  of  the  pelvis,  may  be  extreme; 
from  two  to  three  inches  is  not  imcommon  (Fig.  357). 


554  ORTHOPEDIC  SUBGERY 

2.  Physical  Effects. — The  symptoms  of  coxa  vara  of  the  ordinary 
type  are  discomfort,  awkivardness,  limp,  shortening,  atrophy, 
limitation  of  motion,  deformity. 

Coxa  vara  is  a  more  disabhng  deformity  than  genu  varum  or 
valgum,  and  its  attendant  symptoms  of  discomfort,  weakness, 
and  pain  are,  as  a  rule,  more  marked.  This  is  explained  by  the 
fact  that  in  coxa  vara  the  head  of  the  bone  is  in  part  displaced 
from  the  acetabulum  (Fig.  355),  while  in  the  deformities  at  the 
knee  the  joint  surfaces  remain  in  practically  normal  relation  to 
one  another. 

Fig.    354 


Skiagram  of  coxa  vara;  deformity  most  inaiked  at  the  epiphyseal  j miction.  This  illus- 
trates the  mechanical  limitation  of  abduction  caused  by  the  deformity,  and  the  compensa- 
tory tilting  of  the  pelvis.     The  patient  is  shown  in  Fig.  357. 

The  symptoms  of  unilateral  coxa  vara  vary  with  the  degree 
and  with  the  duration  of  the  deformity.  The  patient  usually 
complains  of  sensations  of  stifi'ness  and  weakness,  referred  to  the 
thigh.  These  are  more  noticeable  on  changing  from  a  position 
of  rest  to  one  of  activity,  and  at  times,  particularly  after  over- 
exertion, there  may  be  actual  pain.  By  far  the  most  important 
symptom  and  tlu;  one  that  almost  always  induces  the  patient  to 
seek  treatment  is  tlie  limp.  This  limp,  accompanied,  as  it  usually 
is,  by  outward  rotation  of  the  foot,  resembles  that  caused  by 
united  fracture  of  th(!  neck  of  the  femur.  On  j)hysi('al  exami- 
nation   the    actual   shortening,    explained    by  the   elevated    and 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     555 

prominent  trochanter  and  the  peculiar  unequal  limitation  of  motion, 
will  make  the  diagnosis  clear.  In  some  instances  there  may  be 
a  marked  degree  of  muscular  sj)asm,  and  there  is  usually  mod- 
erate atrophy  of  the  muscles  of  the  thigh. 

Bilateral  Coxa  Vara.— If  the  deformity  is  bilateral  its  effect 
upon  the  gait  and  attitude  is  more  marked.  The  gait  is  extremely 
awkward,  resembling  somewhat  that  of  knock-knees,  for  the 
limitation  of  abduction  forces  the  patient  to  sway  the  body  from 
side  to  side  in  order  that  the  knees  may  not  interfere;  and  if 
the  deformity  is  extreme  the  limbs  may  be  crossed  over  one  another. 

Fig.  355 


Cross-section  of  the  pelvis  and  the  deformed  femur.     A  scheme  to  show  the  effect  of  the 
deformity  in  limiting  abduction  of  the  limb.     The  dotted  outline  shows  the  normal  relation. 

SO  that  locomotion  may  be  difficult.  In  the  ordinary  form  of 
bilateral  coxa  vara  the  femoral  neck  on  each  side  is  displaced 
backward  as  well  as  downward,  and  as  the  head  of  the  femur 
remains  in  the  aceta])ulum  the  shaft  is  thrown  forward,  so  that 
the  trochanter  is  nearer  the  anterior  superior  spine  tlian  is  normal. 
This  displacement  of  the  support  lessens  the  inclination  of  the 
pelvis  and  consequently  the  normal  lumbar  lordosis.  Bilati^'al  coxa 
vara  is  not  infrequently  accompanied  by  other  deformities,  as, 
for  example,  knock-knee  or  flat-foot  (Fig.  35S). 


556  ORTHOPEDIC  SUEGEBY 

Other-  Varieties  of  Coxa  Vara. — Far  less  often  the  neck  of 
the  femur  may  be  depressed  directly  downward  or  even  down- 
ward and  forward.  In  the  latter  instance  the  effect  of  the  de- 
formity upon  the  function  of  the  joint  is  somewhat  different 
from  that  of  the  ordinaiy  type.  x\bduction  is  limited,  as  in  the 
common  form,  but  inward  rotation  replaces  outward  rotation, 
and  extension  is  limited  in  place  of  Hexion.  This  type  of  deformity 
is  almost  always  bilateral.  It  is  accompanied,  usually,  by  slight 
permanent  flexion  of  the  thighs;  thus  the  lumbar  lordosis  is  exag- 
gerated; whereas,  in  the  ordinary  form  it  is  usually  lessened. 

This  description  applies  to  the  ordinary  types  of  the  deformity 
as  it  is  seen  in  later  childhood  and  in  adolescence.  It  undoubt- 
edly occurs  in  early  life,  but  it  is  masked  by  the  more  noticeable 
distortions  of  other  parts,  and  as  an  isolated  deformity  that  de- 
mands treatment  it  is  uncommon.  One  case  was  observed  by 
the  writer  in  a  rhachitic  child  two  and  one-half  years  of  age. 
The  symptoms,  though  slight,  were  typical,  and  the  diagnosis 
was  confirmed  by  a  Roentgen  picture.  In  other  cases  seen  in 
later  childhood,  the  history  of  more  or  less  discomfort  for  many 
years  seemed  to  indicate  that  the  deformity  was  caused  directly  by 
rhachitis,  and  as  has  been  stated  the  slighter  degrees  of  deformity, 
usually  bilateral,  may  be  demonstrated  on  careful  examination 
in  a  considerable  proportion  of  rhachitic  children,  particularly 
in  those  presenting  the  deformity  of  knock-knee. 

In  the  majority  of  cases  the  symptoms  begin  insidiously, 
although,  in  many  instances,  they  may  follow  injury  or  over- 
exertion. (See  Partial  Epiphyseal  Separation.)  If  the  affection 
begins  in  adolescence  and  is  untreated,  the  period  of  discomfort, 
during  which  the  depression  of  the  neck  may  be  assumed  to  be 
progressive,  is  from  two  to  four  years;  but  if  the  deformity  appears 
at  an  early  age,  the  symptoms,  though  remittent  in  character, 
may  continue  indefinitely.  When  the  resistance  of  the  compressed 
bone  becomes  sufficient  to  ensure  stability  the  discomfort  ceases, 
and  the  disability  becomes  less  marked,  as  nature  accommodates 
the  mechanism  to  the  new  conditions. 

Diagnosis. — In  most  instances  diagnosis  may  be  easily  made, 
and  yet  coxa  vara  is  very  often  mistaken  for  hif  disease;  in  fact, 
we  are  indebted  to  this  mistake  for  most  of  the  specimens  of  the 
deformity  that  have  been  described.  The  essential  differences 
between  the  two  are  as  follows:  In  tuberculous  disease  of  the 
hip  the  motions  of  the  joint  are  limited  in  every  direction  by 
reflex  muscular  spasm,  and,  as  a  rule,  other  evidences  of  the 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     557 


character  of  the  disease  are  apparent.  Coxa  vara  is  a  simple 
deformity;  reflex  muscular  spasm  is  absent,  except  during  exacer- 
bations due  to  injury  or  overstrain,  and  movement  is  not  limited 
in  all  directions,  but  only  in  abduction,  flexion,  and  inward  rota- 


FiG.   356 


Fig.  357 


Coxa  vara,  shmvinn   (lie  prominent  trochanter. 


Itlustratinctheliltinpof  the 
pelvis  and  the  apjiarent  short- 
ening of  the  limb  in  unilateral 
coxa  vara,  .\ctual  shortening, 
three-fourths  of  an  inch;  ap- 
parent shortcninR,  two  and  a 
half  inches.  The  deformity  of 
the  ci)ii)h.vseal  type  was  ap- 
I)arenUy  induced  by  overexer- 
tion. (See  skiagram.  Fig.  354.) 


tioii  when  tlu>  deformity  is  of  the  ordinary  type.  Actual  shortening 
is  a  late  symptom  of  hip  disease,  while  it  is  present  from  the  very 
onset  of  coxa  vara.  It  is  a  shortening  explained  by  the  elevation 
of  the  trochanter  above  N^laton's  line,  while  such  elevation  in 
hip  disease  is  a  sign  of  destruction  either  of  the  head  of  the  bone 
or  of  a  part  of  the  acetabulum. 


558 


OR THOPEDIC  S UBGERT 


The  deformity  might  be  readily  mistaken  for  congenital  dislo- 
cation of  the  hip,  particularly  of  the  anterior  variety,  but  this 
would  be  excluded  by  the  history,  since  coxa  vara  is  an  acquired 
deformity.  The  diagnosis  between  the  two  affections  may  be 
easily  made  on  the  physical  signs  alone.  In  congenital  disloca- 
tion, if  the  thigh  be  flexed  and  adducted  to  its  extreme  limit,  the 
head  and  neck  of  the  displaced  bone  can  be  distinguished  beneath 
the  distended  tissues  of  the  buttock.  In  coxa  vara  nothing  but 
the  prominent  trochanter  can  be  made  out  on  similar  manipula- 
tion, while  the  abnormal  mobility,  characteristic  of  the  dislocation, 


Fig.   358 


Double  coxa  vara  of  advanced  degree,  showing  the  involuntary  crossing  of 
the  limbs  in  fiexion. 

is  absent.  There  is,  however,  a  form  of  anterior  dislocation  in 
which  the  head  of  the  femur  has  a  secure  support  beneath  the 
anterior  superior  spine  in  which  diagnosis  from  the  physical  signs 
alone  may  be  somewhat  more  difficult.  An  a;-ray  picture  will 
always  make  the  distinction  clear,  however. 

Treatment — If  the  deformity  wctc  discovered  in  the  early  stage, 
one  miglit  liopc;  to  clieck  its  progress  by  a  change  in  the  surround- 
ings and  oc'fMipatiou  of  tlic  patient.  Standing,  particularly  in 
the  attitnde  of  rest,  which  throws  additional  weight  U[)on  the 
weakened  part,  should  be  avoided,  and  work  of  any  kind  that 
induces^^the  familiar  syni{>toins  of  strain  should  be  discontinued. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     559 


As  much  time  as  possible  should  be  spent  in  the  open  air,  and 
diet  and  proper  therapeutical  remedies  should  be  employed  if 
evidence  of  constitutional  weakness  or  rhachitis  is  present. 

Locally,  massage  of  the  lim})s  and  joints  and  forcible  manipula- 
tion, with  the  aim  of  overcoming  as  much  of  the  restriction  of  the 


Fig.   359 


Fig.  3G0 


Unilateral  coxa  vara,  showing  the  effect  of 
slight  depression  of  the  neck  of  the  left,  femur 
upon  the  attitude.     (See  Fig.  360.) 

range  of  abduction  as  may  depend 
upon  the  secondary  changes  in  the 
soft  parts,  should  be  employed, 
reinforced  by  regular  gymnastic 
exercises,  with  the  object  of  im- 
proving the  circulation,  upon  which 
the  repair  of  the  weakened  bone 
depends. 

If  the  deformity  is  unilateral  temporary  support  may  be  in- 
dicated. A  perineal  crutch  (Fig.  251)  or,  if  the  circumstances 
of  the  patient  permit,  one  of  the  convalescent  hip  splints  that 


The  patient,  Fig.  3.59,  eight  montli.-^ 
after  cuneiform  osteotomy.  An  abso- 
lute cure,  both  as  regards  symptoms 
and  deformity. 


5(30  ORTHOPEDIC  SURGERY 

permits  motion  at  the  knee,  may  be  nsed  (Fig.  252).  With  sup- 
port during  the  time  of  greatest  strain — that  is,  when  continuous 
walking  or  standing  may  be  acquired — combined  with  proper 
exercises  and  massage,  the  weak  part  may  become  sufficiently 
strong  to  perform  its  function  in  a  year  or  more,  but  supervision 
will  be  necessary  for  a  much  longer  time. 

Operative  Treatment.  Forcible  Abduction. — In  certain  instances 
particularly  those  cases  in  adolescence  in  which  the  symptoms 
have  advanced  rapidly,  it  may  be  inferred  that  the  bony  structure 
of  the  affected  neck  is  congested  and  softened.  One  may  attempt, 
therefore,  to  restore  the  angle  by  forcibly  abducting  the  thigh,  as 
in  the  treatment  of  fracture  or  epiphyseal  separation.  (See  page 
565.)  In  this  manoeuvre  the  head  is  fixed  by  the  lower  portion 
of  the  capsule,  and  the  deformed  neck  is  forced  against  the  upper 
border  of  the  acetabulum  as  illustrated  in  the  diagrams  (Fig.  362). 
If  the  normal  range  of  abduction  can  be  restored,  one  may  infer 
that  the  deformity  has  been  corrected.  The  limb  should  then  be 
fixed  by  a  plaster  spica  bandage  in  this  attitude  of  extreme  abduc- 
tion for  two  months,  or  until  a  time  when  consolidation  in  the  new 
position  is  apparently  complete. 

A  support  should  be  used  for  a  time,  and  the  usual  treatment 
by  massage  and  exercise  should  be  carried  out  during  the  period 
of  convalescence. 

Linear  Osteotomy. — The  simplest  and  most  efficient  means  of 
overcoming  the  distortion  in  older  subjects  is  linear  osteotomy  of 
the  shaft  of  the  femur  just  below  the  trochanter  minor.  This 
may  be  performed  by  the  subcutaneous  method,  as  in  the  correc- 
tion of  the  deformity  of  hip  disease.  When  the  bone  has  been 
divided  the  shaft  is  rotated  inward  to  the  proper  degree,  and  it 
is  then  abducted  to  the  normal  limit;  in  this  attitude  a  plaster 
spica  bandage  is  applied  reaching  from  the  axilla  to  the  toes. 

If  the  deformity  is  bilateral  it  is  often  sufficient  to  operate  on 
the  limb  which  is  most  affected .  When  the  fracture  is  consolidated, 
massage,  exercises,  and  manipulation  are  employed,  as  has  been 
described.  It  may  be  assumed  that  the  increased  blood  supply 
necessitated  Ijy  the  repair  of  the  injury  will  affect  favorably  the 
weakened  bone  as  well.  The  final  result  in  several  cases,  in  which 
the  operation  was  pei-formed  by  the  writer,  was  very  satisfactory. 

Cuneiform  Osteotomy. — In  younger  patients,  unless  the  outward 
rotation  is  marked,  the  deformity  should  be  remedied  by  remval 
of  a  cuneiform  section  of  bone  from  the  upper  extremity  of 
the  shaft  at  the  level   of  the  trochanter   minor    (Fig.  361).     In 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     561 

childhood  the  neck  of  the  femur  is  short  and  the  strain  to  which 
it  is  Hkely  to  be  subjected  shght;  thus  operative  treatment  may 
be  indicated  as  a  prophyhictic  measure.  In  fact,  one  should  treat 
this  deformity  at  the  hip  on  the  same  principles  as  the  similar 
distortions  at  the  knee.  Coxa  vara  cannot  be  rectified  by  mechan- 
ical treatment;  therefore,  unless  it  is  directly  contraindicated 
operative  intervention  should  be  advised. 

In  the  techni(jue  of  this  procedure  there  are  several  points  of 
importance.  First,  the  restriction  of  abduction,  of  ligamentous 
or  muscular  origin,  must  be  overcome  by  vigorous  stretching  and 
massage  of  the  shortened  tissues  before  the  operation  on  the  bone, 
otherwise  it  will  be  difficult  to  l)ring  the  two  fragments  into  proper 
apposition.  x\n  incision  is  made  from  a  point  about  one  inch 
below  the  apex  of  the  trochanter  directly  downward  about  three 
inches  in  length.  The  bone  is  thoroughly  exposed  by  separating 
the  periosteum  from  the  site  of  operation.  The  base  of  the 
wedge  should  be  about  three-cjuarters  of  an  inch  in  breadth, 
directly  opposite  the  trochanter  minor;  the  upper  section  should 
be  practically  at  a  right  angle  with  the  shaft,  the  lower  being 
more  oblique  (Fig.  361,  2).  The  cortical  substance  on  the  inner 
aspect  of  the  bone  should  not  be  divided,  but,  reinforced  by  the 
cartilaginous  trochanter  minor,  should  serve  as  a  hinge  on  which 
the  shaft  of  the  femur  is  gently  forced  outward,  until  the  opening 
is  closed  by  the  apposition  of  the  fragments  after  the  upper  seg- 
ment has  been  fixed  by  contact  with  the  margin  of  the  acetabulum 
(Fig.  361,  3);  thus  the  continuity  of  the  bone  is  preserved.  The 
limb  is  then  fixed  in  the  attitude  of  normal  abduction  by  means  of 
a  plaster  spica  bandage,  which  should  include  the  foot  also,  for 
about  eight  weeks,  or  until  the  union  is  firm.  When  the  limb  is 
brought  to  the  line  of  the  body  the  neck  of  the  femur  is  restored 
to  its  proper  position  (Fig.  361,  4).  This  mechanical  method  of 
apposing  the  fragments  is  far  more  eft'ective  than  any  system  of 
suture.  If  the  operation  is  carefully  conducted  there  can  be  no 
danger  of  displacement,  and  in  this  there  is  a  manifest  advantao-e 
over  a  simple  osteotomy.  In  ordinary  cases  of  this  class,  accord- 
ing to  the  writer's  experience,  the  cure  is  absolute,  both  as  to 
symptoms  and  to  function.  No  after-treatment  other  than  the 
support  of  a  short  I^orenz  spica  for  a  month  or  more  is  reijuired. 

The  opportunity  for  treatment  of  coxa  vara  in  earliest  childhood 
is  rarely  oft'ered.  It  is  usually  the  (Hrect  result  of  rhachitis,  and 
in  the  early  stage  at  least  it  is  probably  accompanied  by  otlier 
rhachitic  distortions.     It   would    be  well,  therefore,  to  examine 

36 


562 


ORTHOPEDIC  SURGERY 


the  hip-joints  of  rhachitic  chiUh'en,  especially  those  who  present 
the  deformity  of  genu  valgum  with  reference  to  this  distortion. 


Fracture  of  the  Neck  of  the  Femur. 

Traumatic  Coxa  Vara. — Fracture  of  the  neck  of  the  femur  in 
childhood,  although  until  recently  unrecognized,  is  by  no  means 
an  uncommon  accident,  since  35  cases  have  come  under  the 
writer's  observation  during  the  past  16  years. 

Fig.   361 


1.  The  normal  femur.  2.  Deprc-^sion  of  the  neck  of  the  femur — coxa  vara.  A.  A  wedge  of 
bone  has  been  reinovefl.  3.  Abduction  of  the  limb  first  fixes  the  upper  segment  by  contact 
with  the  rim  of  the  acetabulum,  then  closes  the  opening  in  the  bone.  4.  Replacement  of 
the  limb  after  union  is  comiileted  elevates  the  neck  to  its  former  position. 

Fracture  of  the  neck  of  the  femur  in  childhood,  however,  differs 
markedly  in  its  symptoms  and  in  its  effects  from  that  in  later 
life.  Although  it  may  be  complete,  it  is  usually  partial,  what  may 
be  termed  the  "green  stick"  variety.  Thus,  the  immediate  effects 
of  the  injury  are  far  usually  less  disa])ling,  and  the  patient  is  often 
able  to  walk  about  within  a  few  days  after  the  accident.  During 
the  period  of  repair  the  limp  and  attendant  discomfort  are  usually 
mistaken  for  symptoms  of  hip  disease. 

The  diagnosis  is  not  difficult.  There  is  a  history  of  injury, 
usually  a  fall  from  a  height  which  confined  the  patient  to  the 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     563 

bed  for  several  days  or  weeks.  On  physical  examination  shorten- 
ing of  "half  an  inch  to  an  inch  is  found,  explained  by  the  corre- 
sponding elevation  of  the  trochanter.  INIotion  in  the  joint  is 
more  or  less  restrained  by  voluntary  and  involuntary  contrac- 
tion of  the  muscles,  but  this  restriction  is  much  more  marked  in 
flexion,  abduction,  and  inward  rotation  than  in  other  directions;  a 
limitation  explained  by  the  nature  of  the  displacement,  the  neck 
of  the  bone  having  been  forced  downward  and  backward. 

The  immediate  effect  of  the  injury  is,  as  has  been  stated,  less 
marked  than  in  the  adult,  but  the  deformity  often  tends  to  increase 

I'iG.   302 


1.  Fracture  of  the  neck  of  the  femur.  2.  Restoration  of  the  normal  angle  by  forcible 
abduction.  3.  The  limb  in  normal  position.  4,  5,  and  6  illustrate  separation  of  the 
epiphysis  of  the  head  of  the  femur  treated  by  the  same  method. 

in  later  years,  because  the  right-angled  relation  of  the  neck  to  the 
shaft  exposes  it  to  greater  strain.  In  a  number  of  the  patients 
examined  several  years  after  the  injury  there  was  an  increase 
of  the  actual  shortening  combined  with  permanent  adduction. 
At  this  time  the  deformity  could  not  have  been  distinguished, 
except  for  the  history,  from  the  ordinary  coxa  vara  of  a  rather 
extreme  degree. 

Treatment. — If  the   diagnosis  is   made  immediately  or  before 
consolidation  is  complete,  one  should  attempt]_to  replace  the  neck 


564  ORTHOPEDIC  SURGERY 

in  its  proper  relation  with  tlie  shaft  in  order  to  restore  normal 
function  and  to  prevent  subsequent  disabihty.  Tliis  may  be 
accomphshed  by  forcing  the  limb  to  the  limit  of  normal  abduction, 
under  ana?sthesia,  thus  utilizing  the  fulcrum  of  the  upper  border 
of  the  acetabulum  to  restore  the  normal  angle  of  the  neck.  In 
this  position  a  plaster  bandage,  reaching  from  the  axilla  to  the 
toes,  should  be  applied   (Fig.  365). 

After  consolidation  of  the  fracture  a  hip  splint  or  Lorenz  spica 
may  be  used  for  several  months  or  until  complete  repair  has 
taken  place.  Massage  and  forcible  manipulation,  if  limitation  of 
motion  remains,  combined  with  the  avoidance  of  overstrain,  should 
restore  function  and  prevent  the  increase  of  the  deformity. 

After  consolidation  the  untreated  fracture  is  practically  a  form 
of  coxa  vara.  In  such  cases  the  neck  of  the  femur  should  be 
replaced  in  its  normal  position  by  the  removal  of  a  sufficient  wedge 
of  bone  from  the  base  of  the  trochanter  as  described  under  the 
treatment  of  simple  coxa  vara  (Fig.  361). 

Traumatic  Separation  of  the  Epiphysis  of  the  Head  of  the  Femur. — 
As  has  been  stated,  in  traumatic  depression  of  the  neck  of  the 
femur  the  fracture  is  usually  at  about  the  centre  of  the  neck, 
which  in  childhood  is  but  little  more  than  an  inch  in  length. 
In  other  instances  the  head  of  the  femur  may  be  partially  or 
completely  separated  at  or  near  the  epiphyseal  line.  This  dis- 
junction is  more  likely  to  occur  in  adolescence  and  particularly 
in  subjects  suffering  from  coxa  vara  in  the  early  stage.  Thus 
sudden  disability,  following  slight  injury,  in  an  adolescent  who 
has  complained  of  discomfort  and  limp  for  some  time  before, 
and  who  presents  on  examination  the  signs  of  depression  of  the 
neck  of  the  femur,  should  suggest  this  accident;  but  the  exact 
diagnosis  can  be  established  only  by  a  Roentgen  picture  or  by 
operation.^ 

The  treatment  is  similar  to  that  of  fracture,  but  the  functional 
derangement  of  the  joint  is  likely  to  be  greater  for  the  reason  that 
the  articulating  surface  of  the  head  of  the  femur  is  involved.'^  If 
disturbance  of  function  is  due  directly  to  the  deformity  the  joint 
slujuld  be  opened  by  the  anterolateral  incision.  The  partly  dis- 
placed licad  may  then  be  completely  separated  by  a  thin  chisel 
and  replaced  in  proper  ])osition,  or,  if  the  deformity  is  slight, 
the  irregularities  that  interfere  with  motion  may  be  removed. 

'   SpreriKel,  Arcliiv  f.  kliii.  Chir,,  1898,  B.  xlvii.,  S.  805.   Clarke,  Lancet,  October  27,  1900. 
-  Whil-rriiiri,  Me'lical  Heoonl,  .July  25,  1893;  Annals    of  Surgery,  June,  1897,  February, 
1899,  and  November,   1902. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA    VARA     565 

Partial  Epiphyseal  Separation  in  Adolescence. — As  has  been  sug- 
gested, slight  injury  may,  under  favoring  conditions,  rupture  the 
periosteum  and  the  cortical  substance  at  the  junction  of  the 
epiphysis  and  the  neck  of  the  femur,  and  luider  the  strain  of  use 
the  head  of  the  bone  may  be  slowly  depressed,  the  final  result 
being  the  epiphyseal  type  of  coxa  vara  that  has  been  described. 
The  symptoms  of  this  variety  of  deformity,  which  is  practically 
limited  to  adolescence,  resemble  those  of  ordinary  coxa  vara, 
except  that  they  are  more  marked  and  more  disabling. 

In  other  cases  the  displacement  may  be  greater  or  practically 
complete,  in  which  case  the  disability  is  immediate,  although  the 
traumatism  was  apparently  very  slight.  This  accident  under  the.se 
conditions  is  very  unusual  in  healthy  children.  Particular  atten- 
tion is  called  to  this  point,  as  the  two  classes  of  cases  are 
usually  confounded,  traumatic  depression  of  the  neck  of  the 
femur  being  classed,  as  a  rule,  as  epiphyseal  separation.^  The 
treatment  has  been  described  in  the  preceding  section. 

Fracture  of  the  Neck  of  the  Femur  in  Adult  Life. — The  treatment 
by  forcible  abduction  and  fixation  recommended  for  incomplete 
fracture  of  the  neck  of  the  femur  or  epiphyseal  separation  in 
childhood,  with  the  aim  of  restoring  symmetry,  applies  also  to  the 
so-called  impacted  fracture  in  older  subjects. 

The  patient  having  been  anaesthetized  is  placed  upon  a  box  of 
sufficient  size,  about  seven  inches  in  height,  the  pelvis  resting  on  a 
sacral  support  and  the  extended  limbs  held  })y  assistants.  That  on 
the  sound  side  is  then  abducted  to  the  normal  limit  to  demonstrate 
the  range  and  to  fix  the  pelvis.  That  on  the  injured  side  is 
then  under  traction  slowly  abducted,  the  surgeon  supporting 
the  joint  with  his  hands  and  pressing  the  trochanter  gently  down- 
ward. The  limitation  of  abduction,  caused  by  contact  of  the 
neck  with  the  deformed  l)order  of  the  acetabulum,  is  recognized, 
but  it  is  easily  overcome.  ^Vhen  the  limit  of  normal  al)ductioii  is 
reached  it  may  be  inferred  that  the  proper  relation  between  the 
neck  and  shaft  of  the  femur  has  been  restored.  The  limb  is  then 
securely  fixed  in  this  attitude  by  a  long  })laster  spica  until  repair 
is  sufficiently  advanced   (Fig.  365). 

If  the  fracture  is  complete  the  same  treatment  is  adopted  with 
the  following  modification.  The  patient  lying  in  the  ])()si(i(»u 
described  with  the  sound  limb  abducted  the  disabled  nuMiibcr 
is  flexed  to  (Hsengage  folds  of  capsule  (liat  may  have  fallen  between 

'  Whitman,  Med.  News.  Soi)tcinl>er  24.  1904. 


566 


ORTHOPEDIC  SURGERY 


Fig.  363 


Impacted  fracture  of  the  neck  of  the  right  femur,  illustrating  the  reduction  of  the  defor- 
mity by  direct  traction  and  abduction.  The  operator  supports  the  joint.  The  left  limb 
is  abducted  to  indicate  the  normal  range,  which  varies  in  different  subjects,  and  to  prevent 
tilting  of  the  pelvis. 


Fig.   364 


B 


A.  (Complete  fra<;ture  of  the  neck  of  the  femur,  illu.slratinR  the  influence  of  the  muscles 
in  increaHini?  the  rllHiilacement.  li.  Complete  fracture,  after  reduction  and  fixation  in  the 
pomtion  of  abduction,  iilustratiiiK  the  security  a.ssured  by  the  direct  contact  of  the  tro- 
chanter willi  tlir;  siiie  of  I  he  pelvis;  also  the  tension  on  the  capsule  and  the  removiil  o!  I  lie 
deforming  influrMice  of  the  muscles. 


CONGENITAL  DISLOCATION  OF  HIP  AND  COXA   VARA     567 

the  frao-ments.  It  is  then  extendefl  and  rotated  to  the  normal 
attitude  and  under  traction  and  counter-traction  the  shortening 
is  completely  overcome,  as  demonstrated  by  measurement.  The 
limb  is  then  slowly  alxlucted  by  the  assistant  while  the  surgeon 
supporting  the  joint  pushes  the  thigh  upward  from  beneath  to 
force  the  two  fragments  against  the  anterior  part  of  the  capsule. 
When  the  limit  of  abduction  has  been  reached  the  capsule  will 
be  tense,  thus  directing  the  fragments  toward  one  another,  the 
trochanter  will  be  apposed  to  the  side  of  the  pelvis,  thus  preventing 
upward  displacement  and  the  tension  of  the  muscles,  which  favors 


Fk;.  :?05 


The  long  spica,  as   applied  for  the   treatment   of    fracture  of  the  neck  of  the  femur  in  tlie 
adult  at  an  angle  of  abduction  of  45  degrees 

deformity,  will  be  completely  relaxed.  A  plaster  spica  is  then 
applied, as  in  the  preceding  instance.  In  the  after-treatment  the 
support  of  a  modified  hip  splint  (Fig.  252)  is  desirable,  and  func- 
tional recovery  will  be  hastened  by  massage  and  by  appropriate 
pressure  and  active  exercises. 

One  often  encounters  cases  in  which  the  disability  persists  after 
fracture  of  the  neck  of  the  femur — a  disability  due  in  great  part 
to  flexion  and  adduction  (k>formity.  Such  deformity  may  be,  in 
many  instances,  reduced  by  moderate  force.  If,  as  is  often  the 
case,  the   fracture  has   failed  to  unite  and  the  open  operation    is 


568  OR THOPEDIC  SURGERY 

impracticable  the  upper  extremity  of  the  femur  may  be  forced 
forward  beneath  the  anterior  superior  spine  and  the  limb  may  be 
fixed  in  an  attitude  of  abduction  and  extension  by  a  short  spica, 
as  originally  suggested  by  Lorenz.' 

Coxa  Valga. 

Coxa  valcja  is  a  term  used  to  simiifv  an  abnormal  elevation  of 
the  neck  of  the  femur  in  its  relation  to  the  shaft,  in  contrast  to 
coxa  vara,  an  abnormal  depression.  This  deformity  is  sometimes 
observed  in  limbs  which  have  never  supported  weight.  It  is  a 
possible  result  of  injury  also.  It  is  of  no  particular  importance 
from  the  orthopedic  standpoint. 

1  The  author's  method  of  treating  fracture  of  the  neck  of  the  femur  is  described  in 
detail  in  the  Amer.  Jour,  of  Med.  Sci.,  July,  1905.  The  Medical  Record,  March  19,  1904. 
The  Therapeutic  Gazette,  May,  1906. 


CHAPTER   XYI. 

DEFORMITIES  OF  THE  BONES  OF  THE  LOWER  EXTREMITY. 

Of  the  distortions  of  the  lower  extremity  bow-leg  and  knock- 
knee  are  by  far  the  most  common,  comprising  abont  15  per  cent, 
of  the  total  cases  in  orthopedic  clinics.  Of  the  two,  bow-leg  is 
the  more  frequent  in  all  tables  of  statistics,  and  it  is  probable 
that  the  proportion  of  bow-leg  to  knock-knee  is  much  larger  than 
would  appear  from  the  hospital  records;  for  genu  valgum  is 
generally  recognized  as  a  serious  deformity,  while  bow-leg  is 
known  to  be  of  little  consequence  except  from  the  {esthetic  stand- 
point, so  that  its  rectification  is  more  often  trusted  to  the  power 
of  nature. 

Both  deformities  appear  to  be  more  common  in  male  than  in 
female  children — a  fact  explained,  perhaps,  by  the  greater  weight 
and  the  greater  susceptibility  of  the  former.  But  here,  again, 
statistics  may  be  influenced  somewhat  by  the  fact  that  bow-leg 
is  considered  to  be  of  more  consecjuence  to  tlie  boy  than  to  the 
girl,  because  of  the  concealment  that  the  skirts  will  ensure  if  the 
distortion  is  not  outm-own  in  childhood. 

Statistics. — The  relative  frecjuency  of  the  two  deformities  may 
be  indicated  by  the  statistics  of  the  Hospital  for  Ruptured 
and  Crippled  for  a  period  of  15  years,  1899-1904.  During  this 
time  8760  cases  were  recorded,  5741  cases  of  bow-leg  (65.5  per 
cent.),  3019  of  knock-knee  (34.5  per  cent.).  Of  the  5741  cases 
of  bow-leg  3401  were  in  males  (59  per  cent.)  and  2340  were 
in  females  (41  per  cent.).  The  3019  cases  of  knock-knee  were 
more  evenly  divided  between  the  sexes,  1601  being  in  males 
(50.04  per  cent.)  and  1409  in  females  (49.06  per  cent.). 

It  will  be  noted  that  94  of  the  cases  of  genu  valgum  were  in 
patients  over  fourteen  years  of  age,  as  compared  with  78  cases 
of  adolescent  or  adult  bow-leg.  The  writer's  personal  expe- 
rience in  the  clinic  enables  him  to  state  that  a  large  proportion  of 
the  cases  of  genu  valgum  actually  developed  or  increased  to  an 
extent  demanding  treatment  during  adolescence,  while  most 
of  the  cases  of  bow-leg  deformity  in  patients  more  than  fourteen 


570  ORTHOPEDIC  SUEGERY 

years  of  age  had  existed  since  early  childhood  or  were  the  result 
of  injury  or  disease. 

The  Etiology  of  Genu  Valgum,  Genu  Varum,  and  of  Other 
Distortions  of  the  Bones  of  the  Lower  Extremity. — The  com- 
mon predisposing  cause  of  simple  deformities  and  disabilities  of 
the  lower  extremities — in  other  words,  those  not  caused  by  local 
injury  or  local  disease — is  the  erect  posture,  when  for  any  reason 
the  bones  and  the  joints  are  unequal  to  the  strain  of  locomotion 
and  to  the  task  of  sustaining  the  weight  of  the  body. 

Time  of  Onset. — At  two  periods  of  life  the  deformities  under 
consideration  most  often  develop.  The  first  is  in  early  childhood, 
when  the  upright  posture  is  first  assumed;  the  second  is  in  adoles- 
cence, when  the  rapid  growth  and  other  changes  incident  to  this 
period  may  lessen  the  stability  of  the  supporting  structures,  and 
when  the  strain  of  laborious  occupation  may  be  added  to  that  of 
the  increasing  weight  of  the  body. 

The  deformities  of  adolescence  are,  however,  relatively  insig- 
nificant in  number  compared  with  those  of  early  childhood,  for  in 
childhood  inherited  weakness  or  weakness  that  is  the  direct 
result  of  malnutrition  at  once  develops  into  deformity  under  the 
strain  of  standing  and  walking.  Thus,  as  a  rule,  the  deformities 
under  consideration  first  attract  attention  soon  after  the  child 
begins  to  walk.  If  the  deformities  are  severe  the  body  usually 
presents  the  evidences  of  general  rhachitis;  in  other  instances  the 
distortion  of  the  legs  is  almost  the  only  sign  of  its  presence,  and 
in  a  certain  number  there  may  be  no  evidence  whatever  of  malnu- 
trition or  disease. 

Predisposition  to  Deformity. — It  is  not  always  easy  to  explain  why 
weak  legs  bend  in  one  way  rather  than  in  another.  In  many 
instances  it  may  be  assumed  that  a  slight  degree  of  deformity  is 
present  before  the  child  begins  to  walk.  For  example,  a  slight  out- 
ward bowing  of  the  legs  is  not  uncommon  in  early  infancy,  and  the 
use  of  heavy  diapers  might  favor  an  increase  of  the  distortion. 
Knock-knee  may  be  induced,  apparently,  by  holding  the  infant 
on  the  arm  with  the  knees  pressed  against  the  chest,  and  certain 
cases  of  kntx-k-knee  and  bow-leg  combined  appear  to  be  caused 
directly  by  this  manner  of  carrying  the  infant  habitually  upon 
one  arm. 

The  legs  of  rhachitic  children  who  have  never  walked  are  often 
somewhat  distorted  and  in  many  instances  this  may  be  explained 
by  the  habitual  postures  (Fig.  3(50). 

A  moderate  degree  of  jjow-leg  is  not  infrequently  seen  in  vigorous 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    571 

infants  who  stand  and  walk  at  an  early  age.  Aside  from  the 
determining  curve  in  the  bone  that  may  be  present  before  the 
child  begins  to  walk,  this  predisposition  toward  bow-leg  may 
be  explained,  perhaps,  by  the  fact  that  young  infants  often  separate 
the  feet  widely  in  walking,  and  the  swa}dng  of  the  body  from  side 
to  side  may  tend  to  bend  the  legs  outward.  In  weaker  or  less 
vigorous  children  a  slight  degree  of  knock-knee  is  not  uncommon, 
induced  more  directly  by  weakness  or  inactivity  of  the  muscles, 

Fig.   366 


Habitual  posture  as  a  factor  in  the  etiology  of  rhachitic  bow-kg. 


as  a  result  of  which  the  child  stands  with  the  knees  somewhat 
flexed  and  pressed  together,  while  the  feet  are  separated  and 
everted,  an  exaggeration  of  the  so-called  attitude  of  rest. 

Bow-leg  is  not  uncommon  in  adult  life,  and  it  is  popularly 
associated  with  strength  and  activity.  Undoubtedly  the  attitudes 
of  activity  would  tend  to  intluce  bow-leg  rather  than  knock- 
knee,  so  that  this  tradition  may  have  a  foundation  of  truth.  It 
is  said  to  be  common  among  those  who  ride  constantly,  and  it 


572  OR  THOPEDIC  SURGERY 

may  be  a  direct  result  of  injurv  or  disease  of  the  knee-joint,  but 
it  mav  be  stated  that  well-marketl  bow-leg  in  an  adult  has  almost 
always  existed  since  childhood.  This  statement  cannot  be  made 
of  genu  valgum,  since  it  may  develop  or  increase  during  ado- 
lescence or  even  in  adult  life.  The  predisposing  cause  is  weak- 
ness or  overstrain,  and,  as  has  been  stated,  in  the  popular  mind 
the  deformity  is  characteristic  of  weakness. 

The  Attitude  of  Rest. — Genu  vaVum  is  an  exaggeration  of 
what  is  known  as  the  attitude  of  rest  or  relaxation,  in  which  the 
weight  of  the  body  is  thrown  in  great  part  upon  the  ligaments  of 
the  three  joints  of  the  lower  extremity.  In  the  attitude  of  rest 
the  pelvis  is  tilted  forward,  the  femora  are  rotated  inward  upon  the 
tibise,  and  the  feet  are  separated  and  everted,  so  that  the  greatest 
strain  falls  upon  the  inner  side  of  the  knees  and  of  the  feet.  Thus, 
what  is  known  as  flat-foot  is  often  combined  with  knock-knee. 
Knock-knee  may  cause  flat-foot,  but  more  often  the  flat-foot 
may  induce  knock-knee,  or  both  may  be  the  effect  of  the  same 
general  cause.  Genu  valgum,  in  the  slighter  degree  at  least, 
may  be  induced  directly  by  improper  attitudes;  but  the  attitudes 
are,  as  a  rule,  the  result  of  overwork  to  which  the  mechanism  is 
subjected;  thus  the  knock-knee  of  adolescence  is  so  common 
among  the  bakers  of  Vienna  that  "baker's  knee"  is  there  synony- 
mous with  genu  valgum. 

Genu  valgum  may  be  secondary  to  distortion  elsewhere.  For 
example,  compensatory  knock-knee  is  usually  combined  with 
extreme  adduction  of  the  thigh ;  it  may  be  the  result  of  the  in- 
activity necessitated  by  the  treatment  of  hip  disease;  it  may  be 
a  direct  result  of  injury,  and  it  is  sometimes  an  accompaniment 
of  osteomyelitis  or  osteoperiostitis  of  the  tibia,  which  causes  an 
overgrowth  and  abnormal  lengthening  of  the  leg.  These  are, 
however,  exceptional  cases  that  should  not  be  classed  with  the 
ordinary  deformity. 

The  Outgrowth  of  Deformity. — In  considering  the  treatment  of 
the  simple  static  deformities  of  the  lower  extremity,  which  are 
usually  the  result  of  a  temporary  weakness  of  structure,  one  must 
first  answer  the  (|u<'stiou,  "Will  not  the  child  outgrow  it?"  This 
belief  in  the  spontaneous  cure  of  deformity  is  very  strong, 
not  only  among  the  laity,  but  among  [)hysicians  as  well;  and  it 
rests  upon  the  common  observation  tliat  crooked  legs  become 
straight,  or  at  least  less  deformed,  with  the  growth  of  the  child. 
In  fact,  if  one  were  to  judge  from  tlie  general  observation  of  the 
efl'ect  of  growth  upf>n  the  (h^formities  of  this  class,  or  even  from 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY     673 

the  tracings  of  the  legs  of  rhachitic  children  taken  from  year  to 
year,  one  might  conclude  that  all  deformities  of  this  class  might 
be  safely  left  to  themselves.  As  an  illustration  of  positive  evi- 
dence on  the  subject,  the  observations  of  Kamps*  on  32  cases  of 
rhachitic  distortion  of  the  lower  extremity  may  be  cited.  Four 
and  one-half  years  after  the  cases  were  first  seen  and  recorded 
examination  showed  that  75  percent,  were  cured,  15.3  per  cent, 
improved,  while  9.7  per  cent,  were  unimproverl.  His  conclu- 
sions are  that  such  deformities  do  not,  as  a  rule,  require  special 
treatment  in  early  childhood,  but  that  after  the  age  of  six  years 
the  prognosis  for  spontaneous  cure  is  unfavorable. 

Veit"  photographed  a  number  of  rhachitic  chiUlren  seen  in  the 
surgical  clinic  of  the  University  of  Berlin,  and  after  a  lapse  of 
two  or  three  years  made  another  series  of  photographs  of  the 
same  patients,  who  had  meanwhile  received  no  treatment.  His 
conclusions  are  similar  to  those  of  Kamps,  namely,  that  surgical 
treatment  is  not  required  for  deformity  of  this  character  in  chil- 
dren less  than  six  years  of  age.  In  two  classes  of  cases,  however, 
the  prognosis  for  spontaneous  cure  is  not  favorable,  those  in 
which  the  growth  has  been  checked  by  the  rhachitic  process,  and 
in  certain  cases  of  extreme  bow-leg,  "O"  legs  (Fig,  367). 

The  rectifying  force  of  nature  acts  in  two  ways.  Assuming 
that  the  deformity  reached  its  limit  during  the  period  of  original 
weakness,  it  must,-  of  course,  become  relatively  less  as  the  body 
increases  in  length  and  size.  In  fact,  the  outgrowth  of  deformity 
has  a  direct  relation  to  the  rapidity  of  growth  during  the 
early  years  of  childhood.  It  must  be  borne  in  mind  also  that 
not  infrequently  rhachitic  bones  are  bent  in  two  or  more  direc- 
tions so  that  knock-knee  and  bow-leg  may  be  coml)ined  in  the 
same  person.  One  may,  therefore,  outgrow  the  bow-leg  while 
the  knock-knee  persists  or  in  time  becomes  less  noticeable.  The 
second  manifestation  of  the  power  of  nature  is  more  positive. 
It  may  be  assumed  that  when  the  deformity  is  progressive  all  the 
tissues  are  affected  by  the  weakness;  consequently  the  attitudes 
of  the  child  are  those  that  can  be  most  easily  assumed  under  tlie 
abnormal  conditions.  But  when  the  primary  cause  of  the  weak- 
ness, in  most  instances  rhachitis,  is  no  longer  operative,  the  muscles 
take  on  new  activity  and  vigor,  and  the  actions  and  attitudes, 
in  spite  of  the  deformity,  become  approximately  normal.  Then, 
according  to  Wolff's  law  of  transformation,  the  internal  structure 

'  BeitriiRc  zur  klin.  Chir.,  B.  xiv.,  H.  1. 
-  Archiv  f.  klia  Chir.,'B.  1.,  S.  130. 


574 


ORTHOPEDIC  SURGERY 


oBT 


of  the  affected  bones  begins  to  change  to  accommodate  itself  to 
the  new  conditions  of  weight  and  strain  indnced  bv  the  change 
in  action  and  attitude;  and  to  this  rearrang-ement  of  the  internal 
structure  the  external  shape  of  the  bones  must  conform  in  a  gradual 
growth  toward  the  normal  contour. 

On  this,  theory  it  is  easily  explained  how  the  natural  outdoor 
life  of  the  country  has  long  been  celebrated  as  an  effective  treat- 
ment for  this  class  of  deformity.  But  it  by  no  means  follows 
that  deformity  is  always  outgrown  even  under  favorable  condi- 
tions.    Improper  attitudes  that  favor  and  cause  deformity  are 

often  observed  among  those  who 
are  free  from  weakness  and  dis- 
ability and  from  the  influences 
of    unfavorable    surroundings  ; 
and  such  attitudes  are,  of  course, 
more  likely  to   persist  in  those 
who  were  once  obliged  to  assume 
them  because  of  weakness  and 
deformity.     Again  the  weakness 
of  structure  or  function  may  be 
an  inherited  peculiarity,  or  it  may 
be  induced  by  disease  or  by  im- 
proper surroundings,  influences 
that   may    continue   for   many 
years  and  thus  serve  to  check  the 
natural  tendency  toward  cure. 
The  observations  on  the  out- 
growth of  deformity  have  been 
confined,  as  a  rule,  to  the  period 
of  childhood,  and  most  often  they 
have  been  made  with  reference 
to  the  more  serious  grades  of  distortion,  which  are  the  direct  result 
of  rhachitis.     It  must  be  borne  in  mind,  however,  that  the  true 
significance  of  these  deformities  in  the  adult  must  be  judged  from 
the  icsthetic  rather  than  from  the  medical  point  of  view,  and  although 
the  extreme  degrees  of  bow-leg  and  knock-knee  are  relatively  rare, 
yet  in  the  minor  grade  both  deformities  are  very  common  in  adult 
males  and  in  all  projxibility  in  adult  females  also. 

In  1887  the  writer^  noted  among  2000  adult  males  observed 
(jn  tl)(!  streets  of  Boston,  400  cases  of  })ow-leg  and  32  cases  of 
knock-knee.     One  may  assume,  th(;ji,  that  the  legs  of  about  one 


A  type  of  deformity  in  whicii  the  prognosis 
as  regards  outgrowth  is  bad. 


'  New  York  Medical  Ucccjid,  July  ao,  1887. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY     575 

adult  male  in  five  deviate  more  or  less  from  the  line  of  symmetry — 
a  conclusion  that  has  been  confirmed  by  many  subsequent  observa- 
tions. It  may  be  admitted  that  a  certain  number  of  the  distortions 
under  consideration  are  acquired  during  adolescence,  but  it  is 
probable  that  the  greater  number  of  those  that  may  be  noted  in 
walkers  upon  the  streets  represent  the  incomplete  outgrowth  of  a 
deformity  of  childhood. 

The  statement  is  often  made  that  these  distortions  of  the  legs 
are  common  in  childhood  but  rare  in  adult  life.      Just  what  the 


Fig.   368 


Extreme  deformities,  the  result  of  infantile  rhachit is.     The  left  leg  forms  practically 
a  right  angle  with  the  thigh.   (See  Fig.  372). 

proportion  may  be  in  childhood  it  is  impossible  to  say,  but  it  is 
not  likely  to  be  greater  than  one  in  five.  One  must  conclude 
that  statistics,  on  which  such  statements  are  based,  have  been 
made  up  from  the  records  of  hospitals  where  it  is  extremely  uncoin- 
mon  for  an  adult  to  apply  for  the  treatment  of  bow-leg,  to  which 
he  has  become  accustomed  since  childhood,  unless  the  deformity 
is  extreme  or  is  attended  by  pain. 


576 


ORTHOPEDIC  SURGERY 


Granting  that  the  power  of  nature  is  quite  sufficient  to  modify 
or  to  cure  even  the  more  extreme  distortions  of  childhood,  still 
it  is  evident  that  this  natural  force  is  often  ineffective  in  com- 
pleting the  cure.  Therefore,  in  doubtful  cases  at  least,  one  should 
lend  assistance  in  that  class  of  patients  likely  to  appreciate  the 
advantage  of  svmmetrv  over  deformity,  even  though  it  be  unat- 
tended  bv  discomfort  or  disability. 


Genu  Valgum. 

Synonyms.  — Knock-knee,  in-knee. 

In  the  erect  posture  the  thighs,  whose  upper  extremities  are 
separated   by  the   pehds   and   by  the  projecting  femoral  necks, 


Fig.  369 


Fig.  370 


Female. 


Male. 


The  ncjnual  inclination  of  the  femora.    (Pfeiffer.) 

incline  slightly  inward  to  the  knees,  forming  an  angle  at  the 
knee,  opening  outward,  of  about  172  degrees.  This  angle  varies 
with  the  breadth  of  the  pelvis,  and  it  is,  therefore,  less  in  adult 
females  than  in  males  (Figs.  369  and  370).  The  internal  condyle 
of  the  femur  is  shgiitly  longer  than  the  e.xternal;  thus  the  iuchna- 
tion  of  the  femur  is  compensated  and  the  plane  of  the  knee-joint 
is  hf)rizontal. 

When  the  inuard  projection  of  the  knees  is  increased  to  a 
noticeable  degree  the  tibia;  are  no  longer  perpendicular;  their 
upper  extremities  incliiK;  inward  so  that  in  the  erect  posture 
the  feet  are  .separated  when  the  knees  are  in  contact  (Fig.  371). 
In  the  slighter  grades  of  knock-knee,  which  are  due  in  great  degree 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    oil 

to  laxity  of  the  ligaments,  the  deformity  is  apparent  only  when 
the  weight  of  the  body  is  borne,  but  in  more  marked  cases,  although 
the  distortion  is  increased  by  the  weight  of  the  body,  it  cannot 
be  overcome  when  this  is  removed,  because  it  depends  upon 
actual  changes  in  the  shape  of  the  bones  themselves. 

As  has  been  stated,  the  normal  inward  inclination  of  the  femur 
is  compensated  by  the  greater  length  of  the  internal  condyle,  and 

Fig.   371 


Adolescent  knock-knee.     Deformity  most  marked  in  the  tibiie.     (See  Fig.  374.) 

in  the  deformity  of  knock-knee  the  plane  of  the  knee-joint  is 
still  preserved  by  an  apparent  elongation  of  the  inner  condyle. 
Formerly  it  was  supposed  that  there  was  an  actual  overgrowth 
of  this  part  of  the  epiphysis  Avhich  caused  the  deformity,  but  the 
observations  of  Mikulicz  and  Macewen  have  shown  that  this 
apparent  lengthening  is  in  reality  due  in  great  part  to  a  deformity 
of  the  lower  extremity  of  the  shaft  of  the  femur,  which  is  so  bent 
that  the  epiphyseal   line  has  an  increased   oblicjuity.     And   the 

37 


578  ORTHOPEDIC  SUEOEBY 

hypothesis  that  bone  grows  more  rapidly  when  reheved  from 
weight  and  strain  has  been  disproved  by  Wolff,  who  has  demon- 
strated that  changes  in  the  bones  are  the  result  of  accommodation 
to  altered  function  and  attitude.  (See  page  238).  The  deformity 
is  not  limited  to  the  femur;  in  most  instances  there  is  a  similar, 
although  usually  slighter,  irregularity  in  the  epiphyseal  line  of 
the  upper  extremity  of  the  tibia,  the  shaft  being  so  bent  that 
when  it  is  placed  in  the  perpendicular  position  its  internal  con- 
dylar surface  is  higher  than  the  external.  In  some  instances  the 
primary  and  principal  deformity  is  of  the  shaft  of  the  tibia,  the 
distortion  being  most  marked  in  its  upper  third  (Fig.  371). 

Changed  Relation  of  the  Femur  and  Tibia. — In  addition  to  the 
direct  deformities  of  the  bones  there  is  a  change  in  the  relation 
of  the  femur  to  the  tibia.  The  former  is  rotated  inward  and  the 
latter  is  rotated  outward.  In  some  instances  there  is  also  a  cer- 
tain degree  of  overextension  at  the  knee.  This  is  more  often 
observed  in  the  adolescent  type,  in  which  there  is  laxity  of  the 
ligaments  (Fig.  371).  In  the  ordinary  form  of  rhachitic  knock- 
knee  in  childhood  the  habitual  attitude  is  one  of  slight  flexion 
at  the  knees,  and  in  extreme  cases  there  may  be  actual  limitation 
of  the  range  of  extension  at  the  knee,  and  at  the  hip  as  well. 

The  Accommodative  Attitude. — When  the  limb  is  fully  extended 
the  deformity  is  most  marked,  because  the  shortened  ligaments 
and  tissues  on  the  outer  aspect  of  the  joint  become  tense,  and 
because  the  outward  rotation  of  the  tibia  is  increased.  As  the 
leg  is  flexed  the  deformity  lessens,  and  in  the  attitude  of  complete 
flexion  it  disappears  (Fig.  374).  This  is  explained  by  the  fact 
that  the  posterior  surface  of  the  condyles  is  not  affected  by  the 
deformity  of  the  shaft,  while  the  relaxation  of  the  ligaments  and 
the  outward  rotation  of  the  femora  allow  the  tibise  to  become 
parallel  with  one  another.  This  accounts  for  the  habitual  attitude 
of  slight  flexion  which  is  so  often  assumed  by  patients  who  thus 
UDconsciously  accommodate  themselves  to  the  (k'formity. 

Secondary  Deformities. — 'i'he  outward  inclination  of  the  leg 
throws  iiKjre  weight  upon  the  inner  border  of  the  foot  and  tends 
to  depress  it  into  the  attitude  of  valgus.  Thus  knock-knee  in 
weak  children  is  often  accompanied  by  flat-foot,  but  in  the  more 
extreme  grades  of  deformity  the  efforts  of  the  patient  to  com- 
pensate for  the  abnonnai  separation  of  the  feet  may  result  in 
habitual  inversion;  in  fact,  comfirmed  and  extreme  knock- 
knee  in  older  subjects  is  usnally  acco]nj)aiiicd  by  a  slight  degree 
of  varus  that   becomes   very  evidtuit  after  the  correction  of  the 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    579 

deformity  by  operation.  Even  in  the  mildest  •  type  of  knock- 
knee  this  compensatory  and  conservative  effort  of  nature  is  shown 
by  the  so-called  pigeon-toed  walk,  which  is  often  the  first  symp- 
tom that  attracts  attention. 

Gait. — The  gait  of  the  patient  with  well-marked  genu  valgum 
is  peculiarly  awkward  and  shambling.  The  knees  "interfere" 
and  must  be  assisted,  as  it  were,  in  the  effort  to  pass  one  another 

Fig.   372 


Skiagram  of  Fin.  36iS,  showing  the  deformity  to  be  due  to  ilistorlions  of  liio  iliap 
of  the  bones,  while  the  epiphyses  are  practically  normal. 


in  walkino;.     In  the  slighter  cases  the  thigh  is  abducted  and  rotated 

or?  o 

outward  at  the  moment  of  passing  its  fellow,  the  movement  l)eing 
then  reversed  as  it,  in  its  turn,  supports  the  weight;  but  in  the  more 
severe  type  this  voluntary  effort  of  the  muscles  of  the  leg  is  not 
sufficient,  and,  in  addition,  the  body  is  swayed  from  side  to  side 
and  the  legs  are  alternately  swung  outward  and  lifted  around  one 
another. 


580 


ORTHOPEDIC  SURGERY 


Fig.   373 


The  deformity  and  the  effects  of  the  deformity  on  the  gait  and 
attitude  are  the  most  important  symptoms,  as  of  other  distortions 
of  similar  origin.  The  patient  is,  as  a  rule,  easily  fatigued,  and 
pain  during  the  progressive  stage,  referred  to  the  inner  side  of 
the  knee,  where  the  ligaments  are  subjected  to  continuous  strain 

is  a  common  symptom,  particu- 
larly in  the  adolescent  type  of 
genu  valgum. 

Unilateral  Knock-knee. — This 
description  refers  particidarly  to 
the  cases  in  which  the  deformity 
is  bilateral.  Not  infrequently  it 
is  unilateral,  the  limb  being  so 
shortened  by  the  distortion  that 
a  well-marked  limp  replaces  the 
swaying  gait.  The  pelvis  is  tilted 
toward  the  short  limb,  while  the 
body  is  inclined  in  the  opposite 
direction,  thus  in  cases  of  long 
standing  a  permanent  curvature 
of  the  lumbar  spine  may  be 
present. 

Knock-knee  Combined  with  Bow- 
leg and  with  General  Rhachitic 
Distortions.  —  Occasionally  the 
unilateral  knock-lsmee  may  be 
accompanied  by  an  outward 
bowing  of  its  fellow;  and  in  the 
marked  distortions  of  the  lower 
extremity,  induced  by  rhachitis, 
the  bones  may  be  twisted  and 
bent  in  various  directions,  al- 
though the  outward  expression 
of  the  deformity  may  be  genu 
valgum.  For  exainpk',  the  femora  may  be  bent  forward  and 
outward  above  and  inward  and  backward  below,  while  the  tibia; 
may  be  bent  inward  above  and  outward  and  forward  below. 

In  other  instances,  especially  in  the  slighter  rhachitic  deformi- 
ties, an  outward  bowing  of  the  leg  may  accompany  a  slight  degree 
of  knock-knee,  so  that  it  may  be  difficult  to  classify  the  deformity. 
In    the   more   extreme   deformities   of    the   rliax'hitic    type   the 
shape  as  well  as  the  contour  of  the  bones  is  markedly  modified,  for 


Deforrnily  of  tlie  femur  in  genu  valgum 
(Mikulicz.) 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    581 


example,  the  internal  border  of  the  tibia  may  become  very  prom- 
inent at  its  upper  extremity,  and  may  project  beneath  the  skin 
like  an  exostosis  (Fig.  375).  A  change  in  the  contour  of  the 
fibula  accompanies  and  corresponds  to  that  of  the  tibia,  although 
it  is,  as  a  rule,  much  less  pronounced.  As  has  been  stated,  the 
internal  structure  or  architecture  of  the  affected  bones  is  changed 
to  accommodate  the  new  static  conditions,  and  according  to 
Wolff  the  internal  change  precedes  the  external  deformity. 

Pathology. — In  knock-knee  due  directly  to  rhachitis  the  changes 
in  the  jjones  and  in  the  epiphyseal  cartilages  are  characteristic 
of  that  aflfection,  but  in  the  milder  grades   of  deformity,  aside 


Fig.   374 


y-" 


/ 


ilU. 


Adolescent  knock-knee,  showing  tlie  disappearance  of  the  deformity  when  legs  are  flexed 

(See  Fig.  371.) 

from  the  change  in  the  contour  of  the  bones,  the  tran.sfonnation 
of  the  internal  structure,  and  in  some  instances  slight  thickeninof 
or  irregularity  of  the  epiphyseal  cartilages,  there  is  little  note- 
worthy change  from  the  normal  (Fig.  373).  The  tissues  on  the 
internal  aspect  of  the  joint  are  relaxed;  those  on  the  outer  side, 
the  lateral  ligaments,  the  capsule,  and  the  biceps  muscle,  are  con- 
tracted and  resist  the  reduction  of  the  deformity.  In  the  interior 
of  the  joint  slight  changes  in  the  articulating  surfaces  of  the  bones 
and  evidences  of  chronic  irritation  of  the  syno\ial  membrane 
have  been  described. 

Measurements. — There  are  various  methods  of  measuring  the 
deformity.    One  of  the  simplest  and  most  practical  is  to  trace 


582 


ORTHOPEDIC  SURGEBY 


the  outlines  on  paper,  while  the  child  is  seated  with  the  limbs 
fully  extended,  the  knees  being  sufficiently  separated  to  allow 
the  pencil  to  pass  between  them.  The  increase  of  the  deformity, 
depending  upon  the  laxity  of  the  ligaments  and  upon  the  outward 
rotation  of  the  tibise,  may  be  estimated  by  measuring  the  distance 
between  the  two  internal  malleoli  when  the  patient  stands,  the 


Fig.   375 


Knock-knee  and  bow-leg. 

knees  being  slightly  separated  as  before,  and  comparing  this 
measurement  with  that  between  the  similar  points  in  the  tracing. 
In  the  early  stage  of  progressive  knock-knee,  particularly  in 
the  type  not  caused  directly  by  rhachitis,  laxity  of  ligaments  and 
the  habitual  assumption  of  the  attitude  of  rest  will  account  for 
the  deformity,  wljich  the  patient  may  be  able  to  overcome,  in 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    583 

great  degree  at  least,  by  voluntary  effort.     Tliis  voluntary  control 
of  the  deformity  is  very  suggestive,  as  indicating  certain  factors 
in  its  etiology,  and  the  principles  that  should  be  followed  in  its 
'  treatment. 

Treatment. — The  treatment  of  the  deformity  under  considera- 
tion may  be  classified  as  expectant,  mechanical,  and  operative. 

Expectant  Treatment  should  not  be  expectant  in  the  sense  that 
nothing  is  done  to  correct  the  deformity,  but  expectant  in  that 
more  positive  treatment  by  braces  or  by  operation  is  (k-laycd  or 
avoided  if  it  proves  to  be  unnecessary. 

During  this  period  the  predisposing  cause  of  the  deformity,  if 
it  is  constitutional,  should  receive  proper  dietetic  or  medicinal 
treatment,  as  already  described  in  the  chapter  on  Rhachitis. 
And,  if  possible,  the  direct  exciting  causes  of  the  deformity  must 
be  removed — that  is  to  say,  the  improper  attitudes,  or,  in  the 
adolescent,  the  predisposing  occupations  should  be  discontinued. 
General  massage  of  the  limbs  may  be  employed  with  advantage; 
in  older  children  special  exercises  may  be  practised,  and  in  all 
cases,  whether  braces  are  used  or  not,  direct  manipulation  of  the 
distorted  limbs  is  of  the  first  importance. 

Manipulation. — The  limbs  should  be  vigorously  massaged  at 
morning  and  night,  and  forcibly  straightened.  The  latter  pro- 
cedure is  conducted  as  follows:  The  patient  is  seated  in  a  chair, 
the  limb  being  fully  extended  so  that  the  deformity  is  made  as 
extreme  as  possible.  One  hand  then  clasps  the  knee,  the  palm 
lying  against  its  inner  aspect;  with  the  other  the  calf  is  grasped 
firmly  and  the  leg  is  then  gently  straightened  over  the  fulcrum 
formed  by  the  palm  of  the  hand,  and  is  held  in  the  corrected 
position  for  a  moment.  This  manipulation  should  be  continued 
with  gradually  increasing  force,  although  not  to  the  extent  of 
causing  actual  pain,  for  ten  minutes  at  least  twice  in  the  day  and 
oftener  if  possible. 

Posture  and  Exercise. — It  has  been  stated  that  genu  valgum  is 
often  accompanied,  especially  in  the  rhachitic  cases,  by  flat-foot, 
while  in  another  type  the  inversion  of  the  feet,  or  in  the  more 
severe  cases  the  actual  fixed  attitude  of  varus,  indicates  the  eft'ort 
of  nature  to  withstand  and  to  compensate  for  the  deformity  at 
the  knee.  This  serves  as  an  indication  for  making  the  soles  of 
the  shoes  thicker  on  the  inner  border,  as  in  the  treatment  of  flat- 
foot,  in  onler  to  throw  the  strain  upon  the  outer  border  of  the 
foot.  The  patient  should  be  instructed  to  walk  with  the  feet 
parallel  wi(h  oii(>  another,  and  for  ohh-r  cliilih-i'n  the  ti|)-toe  excr- 


584 


OR  TH  OPE  Die  S  UB  GEB  Y 


cises,  in  which  the  body  is  raised  upon  the  toes  as  many  times 
as  the  strength  permits,  or  games  or  exercises  in  which  the  legs 
are  extended  should  be  encouraged.  Such  exercises  are  often 
efficacious  in  the  early  stage  of  adolescent  knock-knee,  for,  as 
has  been  mentioned,  genu  valgum  is  an  exaggeration  of  the 
attitude  of  rest;  therefore,  its  progress  should  be  checked  by  the 


Fig.   376 


Fig.   377 


The  Thomas  knook-knee  brace. 


Thomas  knock-knee  braces  with  pelvic  band.  The 
pelvic  band  may  be  divided  also,  the  two  parts  being 
joined  by  straps  (Fig.  378). 


a.ssumption  of  the  attitudes  proper  to  activity.  Bicycle  riding,  and 
particularly  horseback  riding  may  be  recommended  also  in  this 
class  of  cases.  A  careful  record  of  the  deformity  should  be  kept 
during  this  tentative  treatment,  and  if  it  improves  somewhat  one 
is  justified  in  delaying  the  more  radical  measures.  This  question 
may  be  decided,  as  a  nde,  in  three  months  if  instructions  are 
faithfully  t'oilowtid. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    585 

Treatment  by  Braces. — The  most  efficient  brace  for  the  treatment 
of  genu  valgum  is  the  simple  straight  steel  bar  or  splint  extend- 
ing from  the  troclianter  to  the  heel  of  the  shoe,  without  joint  at 
the  knee.  The  greater  efficacy  of  the  rigid  bar  as  compared  with 
the  jointed  brace  is  explained  by  the  fact  that  the  rectifying  force 
acts  constantly  when  the  joint  is  fixed,  and   because,  in   many 

Fig.  378 


Modified  Thomas  knock-knee  braces  applied. 


instances,  the  patient  habitually  flexes  the  knees  so  that  direct 
pressure  cannot  be  made  upon  the  deformity  by  a  brace  that 
permits  this  attitude. 

The  Thomas  Brace. — The  simplest  and  cheapest  brace  is 
that  of  Thomas,  which  consists  of  a  light  steel  bar  provided  with 
a  pad  at  its  upper  end  for  pressure  against  the  trochanter,  while 
the  lower,  rounded  extremity  is  turned  inward  at  a  right  angle, 


586 


ORTHOPEDIC  SURGERY 


Fig.  379 


to  pass  through  the  heel  of  the  shoe.  The  knee  is  fixed  by  a 
posterior  bar  attached  to  a  thigh  and  calf  band,  as  iUustrated  in 
the  figure.  When  the  brace  is  applied  the  knee  is  drawn  back- 
ward and  outward  and  is  attached  firmly  to  the  brace  by  a  roller 
bandage  (Fig.  376). 

In  the  more  extreme  cases  in  which  the  knees  and  thighs  are 
habitually  flexed,  the  addition  of  a  peh-ic  band  attached  to  the 
uprights  by  a  free  joint  at  the  hips  adds  to  the  comfort  and  effi- 
ciency of  the  apparatus,  as  the  attitude  of  outward  or  inward 
rotation  can  be  regulated  by  twisting  the  uprights  slightly.  Or 
preferably  the  pehdc  band  may  be  divided  and  attached  by  means 
of  straps  on  the  front  and  back.  The  uprights  may  be  bent  some- 
what inwartl  at  first,  and  as  the  legs  become  straighter  they  are 

straightened  and  finally  bent 
slightly  outward  to  allow  for  the 
over-correction  of  the  deformity 
(Fig.  378).  Twice  a  day  the 
braces  should  be  removed  for 
massage,  manipulation,  and  for 
voluntary  exercises  of  the  limbs. 
In  most  cases  the  braces  are  not 
employed  at  night,  although  the 
rectification  of  the  deformity  may 
be  hastened  by  their  constant  use. 
If  the  deformity  is  unilateral 
so  that  a  brace  is  required  for 
one  imb  only,  the  other  shoe 
should  be  raised  by  a  cork  sole 
about  three-quarters  of  an  inch 
in  thickness,  to  make  walking 
easier.  Children  soon  become 
accustomed  to  the  braces  and 
walk  easily  in  spite  of  the  ab- 
sence of  joints  at  the  knees. 

Another  simple  and  efficient 
})race  is  that  used  at  the  Chil- 
dren's Hospital  at  Boston  (Fig. 
379).  The  upper  part  of  the 
brace  is  turned  backward  and  upward  to  lie  against  the  buttock, 
and  the  feet  can  be  rotated  in  or  out  by  lengthening  or  shortening 
straps  passing  before-  and  beliind  the  body.  lirac(;s  jointed  at  the 
knee  are  sometimes  employed,  but  they  are,  as  a  rule,  ineffective. 


TO 


JjOiix  ljra<;ft.s  for  kciiu  valKUiii. 
(BrafJfonl  and  Lovett.) 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY      587 

except  in  the  slighter  cases  in  which  the  deformity  depends  iii>oii 
laxity  of  ligaments  rather  than  distortion  of  bone. 

Duration  of  Treatment  by  Braces. — The  (kn-ation  of  the 
brace  treatment  depends,  of  course,  upon  the  degree  of  deformity, 
the  age  of  the  child,  and  upon  the  efficiency  of  the  apparatus. 
From  six  months  to  one  year  of  treatment  by  this  means  is 
usually  required.  The  cure  is  assured  by  the  gradual  adaptation 
of  the  parts  to  the  new  static  conditions.  The  contracted  tissues 
of  the  outer  aspect  of  the  joint  become  lengthened;  the  lax  liga-  • 
ments  on  the  inner  side  contract;  the  internal  structure  of  the 
condyles  and  of  the  adjoining  diaphysis  is  gradually  transformed 
and  at  the  external  contour  of  the  bone  becomes  correspondingly 
straighter.  When  the  braces  are  discarded  attention  should  l>e 
paid  to  the  attitudes,  and  the  exercises  that  have  been  mentioned 
should  be  continued  in  order  that  relapse  may  be  prevented. 

The  Plaster  Bandage. — When  the  bones  are  yielding,  as 
in  young  children,  it  may  be  corrected  rapidly  by  the  repeated 
applications  of  plaster  bandages,  the  limbs  being  straightened  as 
far  as  possible  without  causing  discomfort  at  each  sitting,  or  it 
may  be  corrected  at  once  by  manual  force  under  anaesthesia, 
which  is  the  better  method. 

Operative  Treatment. — Immediate  correction  of  the  deformity, 
when  it  is  at  all  marked,  is,  as  a  rule,  indicated  after  the  age  of 
four  or  five  years,  and  is  a  satisfactory  treatment  at  any  age  except 
during  the  period  of  active  rhachitis.  It  is  perhaps  needless  to 
remark  that  the  necessity  for  operation  implies  neglect  of  proper 
preventive  treatment  or  the  failure  of  the  manipulative  and  me- 
chanical methods,  because  of  their  improper  application.  While 
it  is  possible  to  correct  deformity  of  the  bones  by  mechanical 
treatment  in  cases  far  beyond  this  limit  of  age,  yet  the  time  required 
and  the  discomforts  of  the  treatment  exclude  it  in  all  but  very 
exceptional  cases. 

Osteotomy. — During  a  period  of  five  years  176  cases  of  knock- 
knee  were  operated  on  at  the  Hospital  for  Ruptured  and  Crippled ; 
17  per  cent,  of  the  cases  under  in-treatment.  The  usual  opera- 
tion was  osteotomy  by  means  of  the  small  Vance  osteotome,  the 
so-called  "subcutaneous  osteotomy."  In  a  certain  proportion  of 
the  cases  the  bones  of  the  thigh  and  leg  are  equally  involved  in 
the  deformity.  In  others  the  tibia  is  the  more  distorted,  but  in 
most  instances  the  correction  of  the  deformity  of  the  femur  will 
practically  restore  the  normal  contour  (Fig.  347). 

The  limb  having  been  prepared  in  the  usual  manner  is  semi- 


588  ORTHOPEDIC  SURGERY 

flexed,  and  the  inner  surface  of  the  knee  is  placed  on  a  firm  sand- 
bag. With  the  fingers  the  femur  is  firmly  grasped  just  above  the 
condyles,  so  that  its  size  and  position  may  be  accurately  deter- 
mined, and  the  sharp  osteotome  about  the  size  of  a  lead-pencil  is 
forced  with  its  cutting  edge  parallel  to  the  axis  of  the  thigh  down 
to  the  bone,  at  a  point  about  one  and  a  half  inches  above  the  exter- 
nal tuberosity.  While  it  is  held  firmly  in  position  against  the  bone 
it  is  turned  to  the  transverse  direction  and  is  then  driven  through 
the  cortex,  "Wlien  it  enters  the  medullary  canal,  as  is  made 
e^ident  by  the  lessened  resistance,  it  is  partly  withdrawn  and 
moved  slightly  to  one  side  and  the  other,  and  driven  through  the 
cortical  substance  until  by  gentle  force  the  bone  may  be  fractured. 

Fig.   380 


The  Grattan  osteoclast. 

The  osteotome  is  then  withdrawn;  the  minute  wound  is  covered 
with  a  pa/J  of  dry  gauze,  or,  if  the  oozing  is  profuse,  it  may  be 
closed  with  a  catgut  suture.  The  deformity  is  then  overcorrected 
STifficiently  to  simulate  well-marked  genu  varum,  and  a  plaster 
spica  bandage  is  applied.  If  the  deformity  is  bilateral  both  limbs 
are  operated  upon  at  the  same  sitting. 

The  plaster  bandage  is  continued  for  from  four  to  six  weeks, 
and  it  is  then  usually  supplemented  by  a  brace,  which  may  be 
worn  with  advantage  for  several  months,  because  of  the  laxity 
of  the  ligaments  of  the  knee-joint,  which  usually  accompanies 
extreme  deformity  of  rhachitic  origin.  In  less  marked  cases  and 
in  older  subjects  the  support  is  unnecessary.  Massage  and  exer- 
cises  during  the  stage  of  recovery  should  be  employed  if  possible. 

Incomplete  osteotomy  and   fracture  in   the  manner  describe(J 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    589 

have  been  employed  at  the  Hospital  for  Ruptured  and  Crippled  in 
a  very  large  number  of  cases  without  an  unfavorable  result. 
The  discomfort  is  insignificant,  and  confinement  to  the  bed  after 
the  third  day  is  unnecessary. 

Cuneiform  Osteotomy. — In  the  more  extreme  cases  of  gen- 
eral rhachitic  deformity  of  the  lower  extremity  in  which  the 
tibia  is  implicated,  it  is  sometimes  advisable,  in  addition  to  the 
osteotomy  of  the  femur,  to  remove  a  cuneiform  section  of  bone 
from  the  inner  side  of  the  tibia  just  below  the  epiphysis,  in  order 
to  straighten  the  leg  completely.  In  such  cases  it  is  better  to 
perform  the  second  operation  at  a  later  time,  in  order  that  the 
effect  of  the  femoral  osteotomy  may  be  observed.  In  exceptional 
cases  the  deformity  may  be  practically  confined  to  the  tibia;  in 
such  instances  it  should  be  corrected  by  a  primary  cuneiform  or 
linear  osteotomy. 

Osteoclasis. — Osteoclasis,  Ijy  means  of  the  Grattan  osteoclast, 
is  an  efiective  operation.  With  this  instrument  the  bone  may  be 
broken  above  the  condyles  at  the  desired  point.  The  lower 
resistant  bar  is  applied  over  the  external  condyle,  the  upper 
about  four  inches  higher.  The  limb  is  then  firmly  fixed  by  the 
hands  of  an  assistant,  and  the  breaking  bar  is  screwed  rapidly 
home,  breaking  or  bending  the  bone  at  the  point  of  election. 
The  deformity  is  then  overcorrected  in  the  manner  described. 
Not  infrequently  in  rhachitic  cases  the  principal  or  primary  dis- 
tortion is  of  the  tibia.  In  such  cases  the  correction  is  made  at 
this  point.  If  it  is  necessary  to  operate  upon  both  the  femur 
and  tiie  tibia  the  osteoclast,  which  bends  and  breaks,  is  to  be 
preferred  to  osteotomy. 

The  adolescent  type  of  genu  valgum  is  not  often  extreme. 
As  a  rule,  the  deformity  of  the  bone  is  of  comparatively  short 
duration,  and  it  is  accompanied  by  considerable  laxity  of  liga- 
ments. In  the  more  chronic  cases  the  osteotomy  above  tiie 
condyles  may  be  performed  in  the  manner  described. 

Wolff's  treatment  of  gradual  correction  by  plaster-of-Pai-is 
bandages  ("Etappen  Verband")  and  Lorenz's  method  oi  epiphyseal 
separation  described  in  former  editions  have  been  omittai  as  offer- 
ing no  advantage  over  osteotomy  or  osteoclasis. 

It  may  be  noted  that  paralysis  due  to  injury  of  the  peroneal 
nerve  may  follow  the  correction  of  knock-knee.  In  a  total  of 
1863  operations  by  osteoclasis  reporteil  by  Codivilla^  there  are  34 
instances  of  the  paralysis,  2  of  which  were  permanent. 

1   Zeits.  f .  Orth.  Chir. 


590 


ORTHOPEDIC  SURGERY 


Genu  Varum. 

Synonym.  — Bow-leg. 

The  term  bow-leg  includes,  in  its  popular  sense,  all  the  dis- 
tortions that  cause  a  separation  of  the  knees  when  the  ankles  are 
in  contact  with  one  another.     But,  strictly  speaking,  genu  varum 


Fig 


Fig.  382 


The  genu  varum  type  of  bow-leg,  Hhowiiig  the 
outward  rotation  of  the  femora. 


The  same  patient,  Hhowing  the  separation  of 
the  malleoli  when  the  knees  are  in  contact. 


is  the  reverse  of  genu  valgum — that  is,  the  principal  distortion  is 
at  or  near  the  knee-joint — while  bow-leg,  as  the  name  implies,  is 
a  sirnph^  bowing  of  the  tif)ia  and  fibula,  as  a  rule  near  the  ankle 
joint  (Fig.  .'iSl).     In  true  genu  varum  it  line  (h-opped  from  the 
head  of  the  femur  falls  inside  the  knee  (Fig.  .'j07);  the  inner  condyle 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    591 

of  the  femur  and  the  inner  tuberosity  of  the  tibia  bear  the  greater 
part  of  the  weight;  the  outer  condyle  is  on  the  same  level  or  some- 
what lower  than  the  internal,  and  the  outer  tuberosity  of  the 
tibia  may  be  somewhat  higher  than  the  internal.  The  femur 
is  abducted  and  rotated  outward;  the  tibia  is  rotated  inward. 
These  changes,  it  will  be  noted,  are  the  reverse  of  those  found  in 
genu  valgum.  As  has  been  stated,  the  deformity  of  genu  valgum 
disappears  on  flexion,  and  in  genu  varum,  if  the  limbs  are  flexed 
and  the  knees  are  placed  in  contact  with  one  another,  the  malleoU 
may  be  actually  separated,  simulating  the  deformity  of  knock-knee 
(Fig.  382).  This  is  explained  by  the  inward  rotation  of  the 
femora,  necessitated  by  placing  the  knees  in  contact  with  one 
another. 

In  fremi  varum  the  distortion  of  the  bones  is  not  as  strictlv 
confined  to  the  neighborhood  of  the  knee-joint  as  in  genu  valgum, 
and  in  simple  bow-leg  there  is  almost  always  a  certain  degree  of 
distortion  at  the  knee,  dependent,  in  part,  upon  laxity  of  the 
ligaments.  It  is  proper,  therefore,  to  use  the  two  terms  synony- 
mously, although  one  must  recognize  a  decided  ditterence  between 
the  genu  varum  type,  in  which  the  deformity  is  greatest  at  the 
knee,  and  which  is  accompanied,  as  a  rule,  by  markerl  laxity 
of  the  ligaments  (Fig.  367),  and  the  bow-leg  type,  in  which  the 
deformity  may  be  limited  to  the  lower  third  of  the  leg  (Fig.  388). 

Symptoms. — As  was  said  of  genu  valgum,  the  deformity  is 
the  principal  symptom.  The  gait  is  somewhat  rolling,  Ijecause 
each  foot  must  describe  a  part  of  the  arc  of  a  circle  before  reach- 
ine  the  m-ound;  and  because  of  the  inward  rotation  of  the  tibite, 
or  because  of  the  inward  spiral  twist  of  the  bone  that  is  some- 
times present,  patients  often  toe-in  in  walking. 

Except  in  extreme  cases  the  weakness  and  awkwardness  char- 
acteristic of  genu  valgum  are  absent.  This  may  be  explained  by 
the  fact  that  the  relation  of  the  bones  is  such  that  the  general 
attitude  is  one  of  acti^^ty,  the  weight  falling  on  the  outer  side  of 
the  feet;  thus  the  weak  foot  is  luicommon  as  an  accompaniment 
of  bow-leg,  except  in  the  early  or  rhachitic  type  or  as  a  compensa- 
tory deformity  in  older  subjects. 

Measurements. — The  full  efl'ect  of  the  deformity  appears  only 
when  the  weight  of  the  body  is  borne,  but  for  practical  purposes 
the  tracing  of  the  extended  legs  is  the  best  method  of  recording  the 
fixed  deformity.  In  true  genu  varum  the  deformity  is  greatest 
at  the  knee,  and  in  the  distortion  the  apposed  surfaces  of  the 
femur  and  of  the  tibia  participate. 


592 


OR THOPEDIC  SURGERY 


In  simple  bow-leg  the  deformity  may  be  confined  to  the  tibia, 
which,  in  addition  to  the  outward  bowing,  may  be  twisted  inward 
somewhat  upon  its  long  axis. 

Genu  vanim  may  be  unilateral  or  it  may  be  combined  with 
genu  valgum  of  its  fellow  (Fig.  375),  and  occasionally  slight 
knock-knee  and  slight  bow-leg  may  be  present  in  the  same  limb. 

Treatment.  Expectant  Treatment. — The  slighter  cases  of  bow- 
leg in  early  childhood  may  be  treated  by  manipulation.  The 
leg,  grasped  firmly  at  the  ankle  and  at  the  knee,  is  straightened 


Fig.   383 


(ieiiu  vaniiii  (jl  rhiiclutic  (>rif:;iu  in  iiri  adult. 

with  a  certain  amount  of  force  over  aud  over  aoaiu.  (gradual 
correction  by  this  means  may  be  hastened  by  luakiug  the  sole 
of  the  shoe  slightly  thicker  on  the  outer  border.  This  aids  also 
in  correcting  the  secondary  pigeon-toe,  but  if  the  foot  is  weak,  as  it 
usually  is  in  rhachitic  cases,  this  method  should  not  be  employed, 
as  it  might  induc(;  flat-foot. 

Treatment  by  Braces. — If  the  deformity  is  more  extreme,  or  if 
iinpn^vcnicnt  docs  not  follow  expectant  treatment,  apj)aratus 
should  be  (Mnploycd.     If  the  distortion  is  confined  to  the  lower 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY      £93 


Fig.  384 


third  of  the  tibia  a  Knight  brace  may  be  used.  It  consists  of 
two  uprights  attached  to  a  foot-plate;  the  inner  l)ar  is  provided 
with  a  pad  at  its  upper  end  for  pressure  on  the  internal  condyle 
of  the  femur.  The  outer  bar  reaches  to  the  head  of  the  fibula, 
and  the  two  are  joined  by  a  calf  band  (Fig.  385).  When  applied 
the  leg  is  drawn  toward  the  iinier  upright  by  means  of  a  lacing, 
which  passes  about  it  within  the  outer 
bar.  When  the  lacing  is  made^fast, 
the  outer  bar  is  adjusted  to  the  con- 
tour of  the  leg,  and  thus  it  aids 
somewhat  in  supporting  it  in  an 
improved  position.  The  foot-plate 
may  be  dispensed  with,  and  the  brace 
may  be  attached  to  the  shoe,  and  even 
the  outer  bar  may  be  removed,  leaving 
only  the  upright,  which  is  held  in 
position  by  the  lacing.  The  appa- 
ratus, then,  has  the  appearance  of  a 
gaiter,  and  has  the  advantage  of  being 
inconspicuous,-  although  somewhat 
less  effective  than  the  Knight  brace. 
If  the  support  is  supplemented  by 
vigorous  manipulation  the  deformity 
may  be  corrected,  in  young  chiklren, 
in  about  six  months. 

If  the  outward  bowiup-  of  the  knee 
is  marked  another  form  of  apparatus 
will  be  necessary,  and  its  effective- 
ness will  be  much  increased  if  there 
is  no  joint  at  the  knee.  The  inner  bar  reaches  to  the  upper  third 
of  the  thigh.  kv\  inner  straight  bar  extends  to  the  upper  tliird  of 
the  thigh,  and  is  attached  to  the  outer  bar  by  a  thigh  band.  This 
inner  upright  is  provided  with  a  lacing  of  leather  or  canvas,  similar 
to  that  of  the  short  brace,  which  surrounds  the  knee  and  u])]x>r 
part  of  the  leg,  and  thus  draws  it  toward  an  improved  position. 
(Fig.    3N.r>). 

Another  form  of  brace  is  used  at  the  Boston  Children's  Hos- 
pital, in  which  the  upper  part  of  the  upright  is  curved  upward 
and  outward  just  below  the  groin,  to  a  point  on  a  level  ^\^th  and 
behind  the  trocjianter,  and  is  attached  to  its  fellow  by  means  of 
a  strap  passing  across  the  buttocks  so  that  the,  feet  may  be  some- 
what rotated  outward  if  necessary  (Fig.  384). 

38 


Long  braces  for  genu  varum. 
(Bradford  and  Lovett.) 


594 


ORTHOPEDIC  SURGERY 


Operative  Treatment. — In  children  more  than  four  years  of 
age,  antl  in  cases  of  the  more  extreme  type  at  an  earlier  age,  or 
when  the  opportnnity  for  mechanical  treatment  is  lacking,  or  if 
rapid  cure  is  desired,  operative  correction  of  the  deformity  is  indi- 
cated. Either  osteoclasis  or  osteotomy  may  be  employed,  and 
in  some  instances  manual  force  is  sufficient  for  the  correction  of 
the  deformity.  There  is  but  little  choice  between  the  methods. 
Osteoclasis  is  somewhat  safer  possibly,  and  is  to  be  preferreil  for 
the  younger  patients. 

At  the  Hospital  for  Ruptured  and  Crippled  during  a  period  of  five 
years,  of  12G  patients,  but  5.5  of  the  cases  of  bow-leg  recorded  in 


Fig.    385 


iif;  aiul  short  how-leg  l^raue. 


the  out-door  department  were  admitted  for  operation.  Osteotomy 
is  usually  performed.  The  small  osteotome  is  inserted  on  the 
inner  aspect  of  the  tibia  at  the  point  of  greatest  deformity,  and 
when  the  bone  lias  hecu  sufficiently  weakened  the  fracture  is 
completed  by  mauual  force.  The  fibula  may  be  broken  at  the 
same  time,  or,  as  is  usually  the  case,  it  may  be  simply  bent  out- 
ward. 'J'he  (h'formity  is  overcorrected,  and  a  well-fitting  plaster 
bandage,  including  the  foot  and  extending  to  the  trochanter,  is 
applied. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMFVY    595 


The  patient  usually  remains  in  bed  for  a  few  days;  he  is  then 
dressed,  and  if  he  so  desires  is  allowed  to  stand.  Ahnost  no  pain 
or  discomfort  fohows  the  opei'ation,  and  in  fact,  in  properly 
selected  cases,  it  is  not  only  free  from  danger,  but  it  has  a  very 
decided  advantage  over  the  ordinary  mechanical  treatment.  If  the 
child  is  in  good  condition,  and  if  the  deformity  is  overcorre( ted 
at  the  time  of  operation,  apparatus  will  not  be  recpiired  in  the 
after-treatment;  but  in  many  instances  some  form  of  support  is 
indicated,  usually  l)ecause  slight  deformity,  due  to  laxity  of  liga- 
ments or  to  deformity  of  the  femur,  appears  when  the  weight  of 
the  body  falls  upon  the  legs. 

It  has  been  stated  that  the  deformity  of  bow-legs  depends  in 
part  upon  a  distortion  of  the  femur  as  well  as  of  the  tibia.  As  a 
rule,  the  correction  of  the 
greater  deformity  of  the  tibia 
will  be  sufficient,  but  in  more 
extreme  cases  a  secondary 
osteotomy  above  the  con- 
dyles will  be  necessary.  This 
may  be  performed  simul- 
taneously with  that  on  the 
tibia,  but  it  is  better  to  defer 
it  until  the  effect  of  the  pri- 
mary operation  has  been 
observed. 

Anterior  Bow-leg. 


Fig.  386 


Anterior  bow-leg. 


Synonym. — Anterior  cur- 
vature of  the  tibia. 

Both  bow-leg  and  knock-knee  are  often  seen  in  children  who 
present  no  signs  of  general  rhachitis,  but  anterior  bowing  of  the 
legs  is  almost  always  combined  with  general  rhachitic  distortions 
of  the  lower  extremity,  most  often  with  knock-knee.  These  in 
turn  are  caused  by  marked  distortion  of  the  femora,  which  n;ay 
be  bent  forward  and  outward  above,  and  inward  at  their  lowi  r 
extremities,  "corkscrew  deformity."  In  anterior  bow-leg  the  tibia- 
are  usually  flattened  from  side  to  side,  curved  inward  or  outward 
and  bent  forward,  the  projecting  crests  presenting  sharply  beneath 
the  skin. 

Symptoms. — The  elVect  of  the  anterior  bowing  is  to  throw  the 
weight  forward  upon  the  foot;  thus  the  heels  a]){K'ar  abnormally 


Fig.   3S7 


Long  anterior  curvature  of  the  tibia  and  flat-foot. 
Fig.  388 


liliacliilio  anterior   bow-le(<. 


DEFORMITIES  OF  BONES  OF  LOWER  EXTREMITY    597 

long  and  prominent,  and  tlie  patient  seems  to  sink  forward  at 
each  step  (Fig.  386).  The  knees  are  usually  somewhat  flexed, 
partly  as  the  effect  of  knock-knee,  with  which  the  deformity  is 
usually  combined,  and  the  feet  are,  as  a  rule,  flat.  As  has  been 
stated,  anterior  bowing  is  almost  never  seen  as  an  independent 
deformity  unless  it  is  a  relic  of  the  more  general  distortion  which 
has  been  "outgrown." 

Treatment. — Anterior  curvature  of  the  tibia  must,  as  a  rule, 
be  treated  by  operation.  After  complete  fracture  of  the  tibia 
and  fibula  the  deformity  may  be  overcome  by  forcing  the  bones 
directly  backward.  In  many  instances  tenotomy  of  the  tendo 
Achillis  may  be  required.  Cuneiform  osteotomy  of  the  tibia 
permits  more  perfect  correction,  but  the  final  result  is  equally 
good  after  simple  osteotomy  or  osteoclasis,  and  if  one  succeeds  in 
separating  the  posterior  part  of  the  tibia  so  that  it  may  conform 
to  the  straightened  anterior  border  an  actual  elongation  mav  be 
obtained. 

General  Rhacbitic  Distortions. 

General  rhachitic  distortions  of  the  lower  limbs  have  been 
mentioned  in  connection  with  knock-knee  and  with  anterior 
bow-leg.  A  more  extended  description  is  hardly  necessary.  The 
deformities  are  usually  of  the  knock-knee  type,  and  they  may  be 
treated  on  the  same  general  plan  that  has  been  outlined  in  the 
description  of  the  less  extreme  distortions. 


CHAPTEE    XVII. 

-  DISEASES  OF  THE  NEin^OUS  SYSTEM. 

From  the  orthopedic  standpoint  only  those  diseases  that  directly 
interfere  with  the  function  of  locomotion  or  that  cause  deformity 
and  for  which  local  treatment  is  of  benefit  are  of  special  interest. 
Even  this  limited  class  is  not  often  seen  in  the  early  or  progressive 
stage,  and  it  is  rather  with  the  effects  of  a  disease  that  is  no  longer 
present  than  with  the  disease  itself  that  the  orthopedic  surgeon 
is  especially  concerned. 

The  relative  importance  of  this  branch  of  orthopedic  work  may 
be  illustrated  by  the  statistics  of  the  Hospital  for  Ruptured  and 
Crippled.  In  a  period  of  ten  years  42,124  new  patients  were 
examined  in  the  out-patient  department.  Excluding  cases  that 
cannot  properly  be  classed  as  orthopedic,  38,419  remain.  In 
2441  of  these  the  nervous  system  was  involved  (6.3  per  cent.) ; 
202S  of  the  cases  were  in  yoimg  children;  413  of  the  patients  were 
more  than  fourteen  years  of  age,  and  of  this  number  266  were 
adults. 

Anterior  poliomyelitis  furnished  about  75  per  cent,  of  the 
total  number.  In  20  per  cent,  the  cerebrum  was  involved,  and 
5  per  cent,  were  miscellaneous  cases.  In  611  cases  treated  in  a 
period  of  about  two  years  there  were  463  cases  of  poliomyelitis, 
121  cases  of  paralysis  of  cerebral  origin,  16  cases  of  obstetrical 
I)aralysis,  4  cases  of  pseudohypertrophic  muscular  paralysis,  and 
7  miscellaneous  cases.  These  statistics  will  explain  the  selection 
of  diseases  of  the  nervous  system  for  consideration  and  the  order 
in  whic-Ji  they  are  described. 

Acute   Anterior  Poliomyelitis. 

Synonym. — Infantile  paralysis. 

Pathology. — Anterior  poliomyelitis  is  an  acute  inflammatory 
pnKX'ss  affecting  the  gray  matter  of  the  anterior  cornua  supplied 
by  the  anterior  spinal  arteries.  It  involves  both  the  neuroglia 
and  the  cells,  and  it  results  in  degeneration  and  atro])hy  of  the 
interstitial  tissue  and  of  the  ganglion  cells.' 

•  Htarr,  Loririii.H  and  'l'horni)Han's  System  of  Practical  Medicine. 


DISEASES  OF  THE  NERVOUS  SYSTEM 


599 


111  tlie  acute  fel)rile  form,  comprising  about  three-fourths  of 
the  cases,  tliere  is  an  actual  inflammation;  in  the  other  type  in 
which  tlie  paralysis  is  of  sudden  onset,  unaccompanied  by  consti- 
tutional evidences  of  disease,  the  symptonis  may  be  caused  by 
hemorrhage  or  by  thrombosis. 

The  minute  changes  in  the  cord  are  characteristic  of  infhimma- 
tion,  distended  bloodvessels,  minute  hemorrhages,  infiltrating 
leukocytes,  and  serum.  In  the  early  stage  the  motor  cells  become 
cloudy  in  appearance,  later  they  are  swollen  and  lose  their  distinct 
outlines.  The  degenerative  changes  affect  both  the  cells  and 
neuroglia;  the  afi'ected  gray  matter  shrinks  and  the  nerve  fibres 
atrophy,  and  the  cord  becomes  distinctly  smaller  at  the  seat  of 
the  disease.  When  the  motor  conductivity  of  the  cells  is  cut  off, 
the  muscles  which  are  supplied  by  them  are  paralyzed  and  waste 
away.  The  circulation  in  the  affected  parts  is  impaired,  con- 
tractions and  distortions  appear,  and  growth  is  retarded. 

Etiology. — The  etiology  of  the  disease  is  obscure.  Exposure  to 
heat,  sudden  chilling  of  the  body,  overfatigue,  injury  and  the  like 
are  thought  to  be  predisposing  causes.  The  direct  cause  of  inflam- 
matory disease  of  the  cord  is  supposed  to  be  some  form  of  infection. 

The  disease  affects  the  sexes  in  nearly  equal  numbers,  and  those 
in  perfect  health  as  often  as  those  whose  resistance  is  enfeebled. 
It  sometimes  occurs  in  epidemics,  and  there  are  instances  in  which 
several  members  of  the  same  family  have  been  affected,  but 
usually  the  cases  are  isolated  and  no  adequate  cause  for  the 
disease  can  be  assigned. 

Age. — Acute  anterior  poliomyelitis  is  essentially  a  disease  of 
infancy.  This  is  illustrated  by  the  combined  statistics  of  several 
observers  tabulated  by  Starr.^ 


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.,  before  the  fourth 

year. 

It  is  far  more  common  during  the  warm  months  than  a(  olhor 
seasons,  as  is  illustrated  in  452  cases  tabulated  by  Starr." 

1   Loom  is  aiul  Thompson's  System  of  Practical  Medicine.  "  Loc.  cit. 


000  ORTHOPEDIC  SURGERY 

Janmry 8  ■ 

February 5 

March 20 

AprU 9 

May 18 

June 49  "^   327,  or  72  per  cent., 

July ^'^    V      '^l'^""i"g    ^-^^e    four 

August 1]6|        months,   June   to 

September 65  J       September. 

October 42 

November 11 

December 12 

452 

Distribution  of  the  Paxalysis.^ — The  lower  extremities  are  far 
more  often  paralyzed  than  the  upper.  In  416  of  595  cases, 
tabulated  by  Starr,  the  paralysis  was  limited  to  the  lower  extrem- 
ities, as  contrasted  with  53  cases  in  which  the  upper  extremities 
were  alone  involved. 

Duchenne.     Seeligmiiller .      Sinkler.  Starr.  Total. 

Both  legs 9  14  107  40  170 

Right  le^ 25  15  G3  20  123 

Left  leg 7  27  02  27  123 

Right  arm        ....      5  9  5  7  26 

Left  arm 5  4  8  4  21 

Both  arms        ....      2  1  1  2  6 

All  extremities      ...      5  2  35  5  47 

Arm  and  leg  s  ime  side   .1  2  26  4  33 

Arm  and  leg  oppo.  sides.      2  1  14  8- 

Trunk 1  0  22  3  26 

Three  extremities       .      .      0  0  10  2  12 

62  75  340  lis  595 

Symptoms. — The  disease  usually  is  divided  into  several  stages: 

1.  The  stage  of  onset.  This  is  usually  attended  by  constitu- 
tional symptoms,  by  fever  and  headache,  even  by  convulsions 
and  delirium;  by  vomiting  and  intestinal  disturbance,  and  occa- 
sionally by  severe  pain.  In  most  instances  the  elevation  of  the 
temperature  is  not  extreme,  iior  is  the  constitutional  disturbance 
severe,  and  but  for  the  paralysis  the  attack  would  be  considered 
as  one  of  the  ordinary  illnesses  so  common  in  childhood.  In  some 
ca.ses,  however,  the  fever  is  high,  and  there  may  be  convulsions 
and  prolonged  unconsciousness,  while  in  others  there  may  be  no 
premonitory  symptoms  whatever;  the  child,  apparently  well  at 
night,  wakens  in  the  morning  paralyzed. 

In  many  instances  the  weakness  or  paralysis  caused  by  anterior 
poliomyelitis  of  a  mild  type  is  not  discovered  until  the  child  begins 
to  walk,  when  the  awkward  gait  or  liinp,  or  the  distortion  of  a 
foot,  may  make  it  evident. 

In  a  few  hours  or  a  few  (hiys  after  the  first  symptoms  of  the 
disea.se  the  paralysis  appears;  its  area  may  cxtencJ  slowly  after 


DISEASES  OF  THE  NERVOUS  SYSTEM  601 

it  is  recognized,  or  its  extreme  limit  may  be  reached  at  once. 
This  original  paralysis  is  always  greater  than  that  which  finally 
persists.  The  duration  of  the  first  stage  may  be  from  a  few 
hours  to  a  week. 

2.  Then  follows  a  stationary  period,  lasting  from  a  week  to  a 
month;  the  constitutional  symptoms  cease  but  the  paralysis 
remains. 

3.  This  is  succeeded  by  the  stage  of  partial  recovery,  lasting 
from  one  to  six  months  or  longer.  The  muscles  which  were 
paralyzed  because  of  the  secondary  congestion  and  exudation 
about  the  local  myelitis  recover  their  power  in  whole  or  in  part, 
while  those  muscles  supplied  from  the  area  in  the  cord  in  which 
the  nerve  cells  have  been  destroyed  waste  away.  At  this  time 
the  contractions  and  distortions  in  the  paralyzed  limbs  appear. 

4.  The  chronic  stage.  This  may  be  considered  to  last  until 
adult  age  or  until  the  ultimate  eft'ect  on  the  individual,  due  to 
the  retardation  of  the  growth  and  unbalancing  of  the  mechanical 
equilibrium  of  the  body  may  be  complete. 

The  sensation  of  the  paralyzed  part  is  not  affected  except  in 
the  extreme  cases.  The  temperature  is  lower  from  the  first.  In 
many  instances  the  limb  is  not  only  cold,  but  it  is  congested  and 
blue.  These  circulatory  disturbances  are  caused  primarily  by 
the  interference  with  the  vasomotor  system,  but  they  are  con- 
firmed later  by  the  atrophy  of  the  muscles  and  by  the  permanent 
contraction  of  the  bloodvessels.  Thus,  in  general,  the  impair- 
ment of  the  circulation  corresponds  to  the  degree  of  the  paralysis, 
but  not  absolutely  so.  In  certain  cases  the  paralysis  may  be 
limited  in  extent,  and  yet  the  limb  may  be  cold  and  congested, 
while  in  others  in  which  the  loss  of  power  is  much  greater  the 
temperature  is  but  slightly  lowered  and  the  color  remains  normal. 
The  same  is  true  of  retardation  of  growth.  In  most  instances 
the  ultimate  shortening  of  the  limb  corresponds  to  the  degree  of 
the  paralysis  and  consequent  loss  of  function;  but  occasionally 
cases  are  seen  in  which  the  growth  is  markedly  retarded,  although 
but  few  of  the  muscles  are  paralyzed. 

Diagnosis. — It  is  doubtful  if  the  diagnosis  of  acute  anterior 
poliomyelitis  could  be  made  before  the  stage  of  paralysis.  But 
after  the  paralysis  has  appeared  there  should  be  little  difficulty 
in  interpreting  the  symptoms.  It  is  a  disease  usually  of  acute 
onset,  followed  by  paralysis  of  certain  muscular  groups  or  of 
entire  members.  It  is  a  flaccid  paralysis,  the  reflexes  are  lost, 
the  muscles  no  longer  contract  under  faradism,  and  the  reaction 


602  ORTHOPEDIC  SURGERY 

of  degeneration  soon  appears;  the  tissues  waste,  and  the  circula- 
tion is  impaired  in  the  affected  parts. 

It  is  usual  to  consitler  first  in  differential  diagnosis  the  paralyses 
of  cerebral  origin,  but  this  is  more  for  the  piu'pose  of  calling 
attention  to  the  essential  differences  between  the  two  than  because 
they  are  likely  to  be  confoimded  by  one  acqiuiinted  with  the 
ordinary  characteristics  of  cerebral   and  spinal  tlisease. 

Paralysis  of  Cerebral  Origin  in  Childhood. — The  common  form  is 
hemiplegia.  It  usually  follows  convulsions,  and  the  intelligence 
may  be  impaired.  The  paralysis  is  not  complete,  nor  is  it  limited 
to  groups  of  muscles;  it  is  rather  powerlessness  or  impairment  of 
function,  due  to  loss  of  cerebral  control.  The  reflexes  are  in- 
creased and  limbs  are  stiffened,  not  flaccid.  The  electrical  reac- 
tions are  not  lost  or  changed  in  quality.  Paralysis  of  cerebral 
origin  may  be  also  paraplegic  or  diplegic  in  its  distribution,  but 
in  these  cases  the  general  characteristics  are  the  same  as  in  the 
hemiplegic  form,  except  that  the  intelligence  is  more  markedly 
affected. 

Other  Forms  of  Spinal  Paralysis. — Transverse  myelitis  is  very 
uncommon  in  childhootl.  In  this  disease  the  distribution  is 
equal,  the  reflexes  are  at  first  increased,  and  sensation  as  well  as 
motion   is  lost. 

Pott's  Paraplegia. — In  this  form  of  paralysis,  also,  the  distribu- 
tion is  equal,  the  reflexes  are  increasetl,  and  the  signs  of  the  dis- 
ease of  the  spine  are  always  present. 

Spastic  Spinal  Paraplegia. — In  this  as  in  the  preceding  form 
the  distribution  is  ecjual,  and  the  reflexes  are  exaggerated. 

Rheumatism  and  Joint  Disease. — In  orthopedic  practice  anterior 
poli(jmyelitis  is  not  often  seen  in  the  stage  of  onset  unless  pain 
is  a  prominent  symptom,  when  the  disease  may  be  mistaken  for 
rheumatism  or  for  some  form  of  joint  disease.  Cases  of  this 
type  are  not  uncommon.  The  muscles  are  sensitive  to  pressure 
and  the  movements  of  the  joints  cause  discomfort.  In  certain 
instances  the  paralysis  may  not  be  apparent  on  the  first  examina- 
tion; when  it  does  appear  the  diagnosis  is,  of  course,  established; 
therefore,  the  characteristics  of  diseases  of  the  joints  need  not  be 
detailed. 

Multiple  Neuritis.  M I lUi pic  iieiu'itis  is  usually  a  sequel  of  in- 
fectious diseases,  or  of  metallic;  poisoning.  In  the  cases  due  to 
metallic  poisoning  with  lead  or  arsenic  the  paralysis  usually  begins 
in  the  extensors  of  the  hands  and  feet,  and  is  symmetrical  in  its 
distribution.     This  is  true,  also,  of  the  localized  forms  of  paralysis 


DISEASES  OF  THE  NERVOUS  SYSTEM  603 

followino;  contaofious  diseases  in  which  the  (h)rsal  flexors  of  the 
feet  are  most  often  involved.  In  niultijjle  neuritis  there  is  usually 
local  sensitiveness  lasting  a  longer  time  than  in  poliomyelitis; 
the  paralysis  is  gradual  in  its  onset,  and  sensation  as  well  as 
motion  is  affected. 

Diphtheritic  Paralysis. — Diphtheria  is  the  most  common  cau.se 
of  general  weakness  terminating  in  paralysis,  but  in  the.se  ca.ses 
there  is  usually  a  history  of  the  preceding  di.sease.  The  paralysis 
appears  fir.st  in  the  mu.scles  of  the  throat  and  neck,  and  a  general 
and  increasing  weakness  precedes  for  a  considerable  interval  the 
complete  loss  of  power. 

Weakness.  Pseudoparalysis. — Weakness  caused  by  rhachitis  or 
so-called  pseudoparalysis,  due  to  this  or  to  other  affections,  is 
readily  di.stinguished  from  actual  paralysis  by  pricking  the  part 
with  a  pin,  when  mu.scular  contraction  and  movement  of  the  limb 
will  be  evident.  This  te.st  of  function  is  of  value  in  showing 
the  distribution  of  actual  paralysis.  Loss  of  power  in  the  tibialis 
anticus  muscle,  for  example,  causes  valgus  resembling  closely  the 
ordinary  valgus  due  to  simple  weakness.  In  simple  weakness 
the  child  withdraws  the  foot  from  the  point  of  the  pin,  and  the 
ability  to  move  it  in  all  directions  is  very  evident;  but  if  the  tibialis 
anticus  muscle  is  paralyzed  the  foot  is  always  flexed  in  the  ab- 
ducted attitude.  The  same  test  may  be  made  for  paralysis  of 
other  muscles  or  muscular  groups.  It  is  a  test  that  is  easily 
applied  and  that  is  especially  useful  in  the  examination  of  young 
children. 

Obstetrical  Paralysis. — Paralysis  of  the  arm  due  to  anterior 
poliomyelitis  is  infrecpient  as  compared  with  that  of  the  lower 
extremity.  This  form  might  be  mistaken  for  obstetrical  par- 
alysis, but  the  history  of  the  disability  and  its  distribution  should 
make  the  diagnosis  clear. 

Prognosis. — Only  in  very  rare  instances  does  the  disease  of 
itself  cause  death.  The  prognosis  as  to  function  depends  pri- 
marily upon  the  area  of  the  destructive  disease  of  the  cord, 
secondarily  upon  the  treatment  of  the  weakened  or  disai)led  part. 
As  has  been  stated,  the  extent  of  the  primary  ])aralysis  is  very 
much  greater  than  that  which  ultimately  remains  when  the  inHam- 
matory  changes  al)()ut  the  disea.sed  area  in  the  cord  have  subsided. 

The  Electrical  Test. — During  the  early  stages  of  the  disease  the 
degree  of  final  paralysis  may  be  fairly  e.stiinated  by  the  electrical 
reaction.  AYithin  a  week  after  the  initial  paralysis  the  reaction 
to  the  faradic  current  in  the  mu.scles  and  nerves  in  direct  con- 


604  ORTHOPEDIC  SVRGERY 

nection  with  the  diseased  area  is  lessened  and  is  soon  lost.  If 
the  faradic  irritability  is  retained  in  the  paralyzed  muscles,  or  if 
it  is  merely  diminished,  recovery  may  be  predicted.  The  nmscles 
which  no  longer  react  to  the  faradic  irritation  may  still  be  made 
to  contract  bv  the  p-alvanic  current.  In  normal  muscles  the 
reaction  is  greatest  at  the  closing  of  the  negative  pole.  In  the 
paralyzed  muscles  the  reaction  is  slower,  it  requires  stronger  stimu- 
lation, and  the  contraction  is  greater  at  the  closing  of  the  positive 
pole.     This  is  known  as  the  reaction  of  degeneration.     The  loss 

Fig.   389 


Anterior  [joliomyelitis.     Extreme  flexion  deformity  at  the  hips,  inducing  quadrupedal 
locomotion.     (Gibney.) 

of  faradic  reaction  and  the  change  in  the  galvanic  reaction  indicate 
that  the  function  of  the  affected  muscle  is  lost,  although  certain  of 
its  fil)res  may  in  time  regain  their  power. 

The  Effects  of  Paralysis  of  Different  Muscles  and  Groups  of  Muscles 
upon  Function. — I'lie  principal  interest  in  anterior  poliomyelitis 
lies  in  its  immediate  and  ultimate  effects  upon  the  functional 
ability  of  the  individual.  These  effects  may  be  classified  as 
deformity  of  the  pari  directly  involved  and  the  influence  of  weak- 
ness, deformity,  and  loss  of  ynnvth  upon  the  body  as  a  whole. 

Causes  of  Deformity. — 'J'lie  deformities  of  anterior  poliomyelitis 
are  caused : 


DISEASES  OF  THE  NERVOUS  SYSTEM  f^Oo 

1.  By  force  of  gravity. 

2.  By  the  unopposed  action  of  the  muscles  whose  power  remains. 

3.  By  functional  use. 

All  these  and  other  less  important  causes  of  deformity  are,  of 
course,  combined  in  most  instances.  The  relative  importance  of 
each  factor  varies,  according  to  the  muscular  group  that  is  involvetl, 
with  the  age  of  the  patient,  and  with  the  strain  to  which  the  part 
is  subjected.  The  influence  of  the  different  factors  can  be  studied 
best  in  the  foot. 

Muscular  Action  and  Gravity. — In  by  far  the  larger  nuiiilx  r  of 
cases,  one  or  more  of  the  dorsal  flexors  of  the  foot  are  involved. 
This  is  illustrated  by  the  statistics  of  acquired  talipes,  tabulated 
elsewhere,  the  equinus  type  of  deformity  being  three  times  as 
common  as  the  calcaneus  form. 

If  the  anterior  muscles  are  paralyzed  before  the  walking  age, 
the  foot  drops  under  the  influence  of  tlie  force  of  gravity  into 
the  attitude  of  equinus.  If  this  attitude  is  allowed  to  persist,  the 
muscles  on  the  posterior  aspect  of  the  limb,  accommodating 
themselves  to  the  habitual  attitude  become  structurally  shortened. 
In  such  cases  the  equinus  deformity  is  caused  by  the  force  of 
gravity;  it  is  increased  by  muscular  action  and  it  is  fixed  by 
muscular  adaptation.  That  deformity  is  not  caused  ('irectly  by 
muscular  action  is  shown  by  the  fact  that  it  may  be  prevented  by 
stimulating  the  paralyzed  muscles  from  time  to  time  with  galvanism, 
or  even  by  systematic  passive  movements  to  the  limit  of  dorsal 
flexion.  Deformity  is  thus  prevented,  not  by  opposing  muscular 
action,  but  by  stretching  the  active  muscles  to  the  full  limit  and 
thus  preventing  muscular  adaptation  and  structural  change.  In 
the  instance  cited  gravity  and  muscular  activity  are  combined 
in  the  production  of  equimis,  but  in  other  instances  gravity  and 
muscular  power  may  be  opposed  to  one  another.  If,  for  example, 
the  calf  muscle  is  paralyzed  while  the  anterior  group  retains  its 
power,  the  deformity  of  calcaneus  does  not  appear  until  the  child 
begins  to  use  the  foot,  when  the  peculiar  helplessness  calls  atten- 
tion to  the  disability,  if  the  diagnosis  has  not  been  made  before. 
Thus  it  is  that  equinus  may  be  present  when  the  child  is  still 
in  arms,  while  the  opposite  deformity  develops  much  more  slowly. 

Habitual  Posture. — There  are  other  cases  in  which  every  ves- 
tige of  muscular  power  is  lost  and  in  which  the  foot  dangles. 
In  this  class  there  is  no  functional  activity  or  tonic  contraction  of 
the  muscles;  conse(|uently  deformity  is  slow  in  making  its  aj)j)car- 
ance;  it  is  not  often  extreme,  and  it  becomes  fixed  onlv  bv  the 


606 


ORTHOPEDIC  SURGERY 


Fio.  390 


structural  shortenino-  of  inactive  tissues,  the  lip-aments,  fascic\?, 
and  the  atrophied  muscles.  There  are,  of  course,  other  causes 
for  habitiuil  posture  than  the  force  of  gra^^ty  and  muscular  action, 
such  as,  for  example,  the  position  of  convenience  in  which  a  weak 
or  disabled  part  might  be  placed,  but  such  causes  of  deformity 

may  be  considered  as  instances 
of  functional  use  or  rather  of 
adaptation  to  local  weakness. 

Functional  Use  as  a  Cause  of 
Deformity.^ — Thus  far  the  force 
of  gravity,  unbalanced  muscular 
power,  and  the  structural  changes 
in  the  tissues  have  been  consid- 
ered in  the  etiology  of  deformity 
as  it  might  develop  in  infancy 
When,  however,  the  patient 
stands  and  walks,  existing  de- 
formities are  exaggerated  and 
confirmed  bv  the  weig-ht  of  the 
body  falling  on  the  unbalanced 
part,  and  by  the  action  of  the 
muscles  in  the  attempt  to  supply 
the  function  of  those  that  are 
paralyzed.  Thus  it  is  that  the 
deformity  develops  far  more 
rapidly  when  a  fair  amount  of 
muscular  power  remains  than 
when  it  is  completely  lost.  (See 
Talipes.) 

Subluxation. — xVside  from  the 
distortions  due  to  the  causes  that 
have  been  mentioned,  there  are 
others  induced  simply  by  weak- 
ness; for  example,  laxity  of  liga- 
ments and   the  failure  of  mus- 

Anlcriiir    imlioipiycrlil  is.      Dmatioii    .seven  ,  •■       T 

year.-.      Showii.K  atr<.).hy  an.l  .sliKht  lateral  t^ular     SUppOrtmay    permit    dlS- 

curvature  of  the  .spine;  two  an.l  a  quarter  t^rtiou  of  a  Hmb  and  SubluX- 
incliew  of  xtiorteninj;. 

ation  or  even  displacement  at  a 
joint  fFigs.  oOl  and  .'j02j.  Comj)lete  (lis])lacement  is  uncommon, 
and  occurs  pracliciilly  only  at  tlu;  hip.  In  such  cases  there  is 
usually  flexion  deformity  of  the  limb,  the  femur  being  suspended 
by  the  contracted   tissues  attached  to  tlic  anterioi-  sn])cri()r  spine. 


DISEASES  OF  THE  NERVOUS  SYSTEM  607 

This  unyieldinir  l)aii(l  forms  a  fiilcrimi  l)y  iiu-ans  of  wliidi  force 
applied  at  the  knee  may  cause  sudden  displacement  of  the  liead 
of  the  femur  inward  or  upwanl  and  backward. 

Deformities  of  the  Upper  Extremity. — Dtformities  cau-sed  by 
paralysis  of  tlie  muscles  of  the  shoulder  are  usually  slitrht 
because  the  part  is  not  subjected  to  the  strain  of  weight  bear- 
ing, an!  because  the  force  of  gravity  is  opjwsed  to  mu.scular  con- 
traction. In  these  cases  the  loss  of  support  and  the  tension 
on  the  capsule  allow  a  considerable  separation  of  the  joint  sur- 
faces so  that  the  atrophied  head  of  the  humerus  may  be  displaced 
forward  or  backward;  but  there  is  not  often  fixed  disj)lacement, 
and  consecjuently  persistent  distortion  due  to  this  cau.se  is  un- 
usual. 

Paralysis  of  the  muscles  of  the  forearm  and  of  the  hand  is  fol- 
lowed after  a  time  by  deformity  of  the  fingers,  caused  primarily 
by  unopposed  muscular  action,  secondarily  by  accommodation 
and  atrophy. 

Deformities  of  the  Neck. — Paralysis  of  one  or  more  of  the 
muscles  of  the  neck  may  induce  a  paralytic  torticollis.  This 
is,  however,  uncommon. 

Deformities  of  the  Trunk. — Paralysis  of  the  muscles  of  the  trunk 
may  induce  distortion  and  extreme  lateral  curvature  of  the  spine. 
This  curvature  is  not  usually  caused,  as  might  at  first  appear, 
by  contraction  of  the  active  muscles  and  thus  a  bending  of  the 
trunk  with  a  convexity  toward  the  Aveaker  side.  As  a  rule,  the 
curvature  is,  as  a  whole,  in  the  opposite  direction.  This  is  ex- 
plained by  the  fact  that  if  the  paralysis  is  limited  to  one  side 
and  is  extensive  enough  to  cause  distortion  of  the  trunk,  the 
muscles  of  respiration  being  involved,  the  chest  wall  becomes 
iiuictive  and  collapses.  In  compensation  the  opposite  side  of 
the  thorax  increases  in  volume  and  lung  capacity  and  the  weak, 
atrophied,  and  sunken  side  is  drawn  towar«l  it.  The  same  effect 
is  observed  wlien  the  arm  and  the  shoulder  muscles  are  paralvzed, 
the  spine  bending  toward  the  side  that  is  still  active. 

Paralysis  of  the  posterior  group  of  muscles,  if  extreme,  may 
induce  ky})h().sis.  Paralysis  of  the  nm.scles  of  the  abdomen  may 
cause  lordosis,  but  in  this  group  of  cases  the  lower  extremities 
are  usually  involved,  and  the  secondary  distortions  due  to  |)osture 
and  to  functional  use  mask  the  direct  eflFect  of  the  paralvsis  of 
the  muscles  of  the  trunk.  And,  again,  the  overuse  of  the  arm 
muscles  in  patients  whose  lower  extremities  are  paraly/ed.  and 
the  susj)ension   of  (lie   body  on   crutches   in   walkinn-,   modifv   tjie 


608 


OBTHOPEDIC  SUBGEEY 


ultimate  effects  in  those  cases  in   which  the  paralysis  is  wide- 
spread in  its  area.   (See  Lateral  Curvature.) 

Retardation  of  Growth  and  Secondary  Deformities. — The  effects 
of  anterior  poliomyelitis  are  not  limited  to  the  paralysis  and  to 
atrophy  of  the  muscles,  but  all  the  component  tissues  of  the 
affected  \\\wh  are  involved  as  well.     The  bones  become  relatively 


Fu;.   391 


Anterior   iioliDinyclitis,  causing  germ  recurvatuni.     (See  Fig.  392.) 

atrophied,  and  their  growth  is  retarded  to  a  degree  fairly  pr()})or- 
ticMiate  to  the  extent  of  the  j)aralysis  and  to  the  functional  dis- 
ability that  has  resulted.  As  has  been  stated,  retardation  of  growth 
does  not  always  corresjyond  to  the  amount  of  })aralysis.  Tn  some 
instances  |)aralysis  ol'  a  single  nmscle,  which  does  not  seriously 
compromi.se  the  function  of  the  part,  is  accompanied  by  greater 


DfSEASES  OF  THE  NERVOUS  SYSTEM 


609 


shortening  of  the  Hmb  than  in  other  cases  in  which  the  paralysis 
is  far  more  extensive.  Thus  it  may  be  inferred  that  certain 
cells  in  the  spinal  cord  are  especially  concerned  in  the  growth 
and  nutrition  of  the  bones,  and  that  interference  with  the  function 
of  these  cells  may  not  correspond  absolutely  to  the  extent  of  the 
destructive  process.  However  this  may  be,  it  is  certain  that 
atrophy  and  retardation  of  growth  are  much  greater  when  a 
limb  is  not  used  than  when  by  the  aid  of  apparatus  it  has  been 
enabled  to  carry  out,  in  part  at  least,  its  proper  function.  It  is 
evident,  also,  that  retardation  of  growth  will  l)e  more  marked 
during  the  period  of  rapid  development;  thus,  the  younger  the 
patient  the  greater  should  be  the  ultimate  inequality  of  the  limbs. 
Retardation  of  Growth. — The  ultimate  shortening  varies 
from  one  to  three  inches.     In  the  slighter  degrees  of  paralysis 


Fin.    392 


1^ 

i 

1 

1 

\    ]^^^^p. 

■1 

—  -  - 

fWI^^B^^^^^HH  .^ 

Anterior  poliomyelitis.    Paralysis  of  muscles  at  the  hip  aliow.s  subluxation  of  the  femur. 
The  same  patient  as  in  Fig.  391. 


affecting  the  leg  the  shortening  may  be  less  than  an  inch,  l)ut 
when  the  thigh  muscles  are  paralyzed  also  it  may  be  much  more 
(Fig.  390).  This  inecjuality  is  usually  very  evident  in  the  size 
of  the  two  feet. 

When  both  limbs  are  paralyzed,  so  that  locomotion  is  very 
seriously  interfered  with,  the  retardation  of  growth  is  especially 
marked,  and  the  contrast  between  the  trunk  of  the  patient  and 
the  attenuated  lower  extremities  is  very  striking. 

Secondary  Deformities  must  include,  besides  those  already 
mentioned,  the  compensatory  distortions  of  the  trunk  that  may 
follow  paralysis  of  the  liml)s.  Thus  a  short  leg  might  cause  a 
lateral  curvature  of  the  spine,  or  great  flexion  contraction  of  the 
thigh  might  induce  abnormal  lordosis.  As  a  matter  of  fact,  the 
final  effects  of  disabilities  of  this  character  are  very  complex,  and 

39 


610  ORTHOPEDIC  S UEGEB  Y 

are  infliiencetl  1)V  maiiv  factors  of  "svhich  onlv  a  sjeneral  indication 
is  practicable. 

Treatment. — The  treatment  of  the  acnte  stage  of  anterior 
pohomyehtis  is  symptomatic.  If  the  diagnosis  has  been  made, 
such  measures  as  would  tend  to  relieve  the  congestion  about  the  dis- 
eased area  should  be  employed;  cathartics,  sedatives,  and  counter- 
irritation  of  the  spine,  for  example.  When  the  acute  symp- 
toms have  subsided  local  treatment  to  maintain  as  far  as  possible 
the  nutrition  of  the  muscles,  to  prevent  deformity  and  to  relieve 
the  strain  upon  the  weakened  tissues,  is  indicated.  The  nutrition 
of  the  parts  may  be  improved  by  massage,  by  muscle-beating, 
by  the  direct  application  of  heat  to  the  cold  extremities,  and  by 
the  use  of  galvanism,  as  long  as  it  will  induce  contraction  of  the 
paralyzed  muscles. 

Deformity  may  be  prevented  by  moving  each  joint  to  the  limit 
of  the  range  of  motion  in  all  directions  several  times  a  day,  and 
by  supporting  the  limb  with  appropriate  apparatus.  Deformity 
in  those  parts  in  which  it  is  favored  by  muscular  action  and  by 
the  force  of  gravity  appears  much  more  rapidly  than  is  generally 
supposed.  The  indications  of  equinus,  for  example,  are  apparent 
within  a  few  weeks  after  paralysis  of  the  anterior  muscles  of  the 
leg.  The  first  indication  of  such  deformity  in  this  class  is  the 
discomfort  caused  by  passively  moving  the  foot  toward  dorsal 
flexion.  This  limitation  of  the  range  of  motion  rapidly  increases, 
and  as  it  increases  it  is  confirmed  by  muscular  adaptation  and 
finally  by  structural  shortening. 

The  Principles  of  Mechanical  Treatment. — The  object  of  a  brace 
is  to  prevent  the  deformity  due  to  weakness  and  to  utilize  the 
muscular  power  that  remains,  so  that  the  disabled  member  may 
carry  out  its  function.  As  each  muscle  has  an  essential  function 
the  paralysis  of  any  one  must  be  followed  by  a  certain  disability 
and  usually  l)y  deformity.  Muscles  vary  in  importance  as  they  do 
in  strength,  and  the  ultimate  disability  caused  by  paralysis  may  be 
predicted  very  accurately  by  one  who  is  familiar  with  this  function. 

Paralysis  of  tjtk  Anterior  Muscles  of  the  IvEg. — Par- 
alysis of  the  anterior  leg  group  causes  the  so-called  steppage  gait; 
the  toes  drag  on  the  floor  when  the  liml)  is  swung  forward,  and 
this  necessitates  an  awkward  lifting  of  the  knee.  'J'h(>  result  of 
snch  j^aralysis  is  (•(piinus.  Slight  e()uiinis  lias  a  tendency  to 
throw  the  knee  backward,  "recurvatuni,"  in  order  that  the 
patient  may  place  the  entire  sole  on  the  gronnd.  More  marked 
equinus  obliges  the  j)atient  to  bear  the  weight    entirely  on  the 


DISEASES  OF  THE  NERVOUS  SYSTEM 


611 


front  of  the  foot,  and  causes  flexion  both  at  the  knee  and  hip. 
If  but  one  of  the  muscles  of  the  anterior  group  is  paralyzed  the 
tendency  to  ecjuinus  is  in  so  far  lessened,  but  there  is  an  inclina- 
tion to  lateral  distortion.  Paralysis  of  the  anterior  muscles  causes 
an  awkward  gait  and  often  deformity,  but  the  propelling  force  of 
the  limb  remains.  The  indication  for  support  is  simple,  to  pre- 
vent the  foot  from  dropping  to  the  extent  that  incommodes  the 
patient,  or  practically  to  hold  the  foot  at  a  right  angle  with  the 
leg. 

Paralysis   of  the  Posterior   Muscles   of  the    Leg. — If, 
on  the  other  hand,  the  calf  muscle  is  paralyzed  the  resistance  of 


Fri.  39.i 


Fh;.  .•?94 


d^ 


<^:d^ 


The  Jurlson  brace  for  paralysis  of  the  quadriceps  extensor  muscle  in  connection 
with  deformity  of  the  foot. 


the  foot  is  lost  and  it  is  simply  dorsiflexed  when  weight  is  thrown 
upon  it.  Thus  the  brace  must  be  arranged  to  prevent  dorsal 
flexion,  and  it  must  be  strong  enough  to  support  the  strain  which 
is  transmitted  from  the  foot-plate  of  the  brace  to  the  front  of 
the  leg.  The  various  weaknesses  and  deformities  of  the  fo(4  and 
the  means  of  treatino;  them  are  described  at  lenjjth  elsewhere. 
(See  Talipes.) 

Paralysis  of   the  calf    muscle  not  only  att'ects  the  foot,  but  it 
weakens  the  knee  as  well,  and  genu  recurvatum  is  often  a  second- 


612 


ORTHOPEDIC  SURGERY 


arv  effect.  In  many  instances,  therefore,  it  will  be  necessary 
to  support  the  knee  as  well  as  the  anlde  during  the  earlier 
stasres  of  the  treatment. 


Fig.  39r) 


Fio.  390 


A  brace  for  complete  paralysis  of  the 
limb,  showinK  a  form  of  lock  at  the 
knee  and  a  limited  joint  at  the  ankle. 


Anterior  iioiioinyelitis.  Paralysis  of  the 
anterior  and  posterior  m\iscles.  Ilecur- 
vation  of  the  right  knee. 


Paralysis  of  the  Tjiigm  Muscles. — Paralysis  of  the  quad- 
riceps extensor  muscle  causes  primarily  a  peculiar  gait.  I'he 
patient,  unable  to  extend  the  leg  upon  the  thigh,  throws  or  swings 
it  forward,  then  locks  the  joint  by  direct  contact  of  the^bones 
and   by  the  resistance  of  the  posterior  tissues,  by  inclining  the 


D [SEA SES  OF  THE  NEB  VO  US  S  YSTEM  Q 1 3 

body  somewhat  forward  as  the  weight  falls  upon  it.  In  this 
manner,  again,  the  knee  may  be  overextended.  Or  if  exten.sion 
is  checked  by  shortening  of  the  tissues,  induced,  for  example, 
by  habitual  assumption  of  the  sitting  posture,  the  patient  being 
unable  to  lock  the  joint  effectively  by  complete  contact  of  the 
})ones,  often  trips  and  falls  because  of  the  insecurity  of  the  sup- 
port. When  in  the  normal  subject  the  weight  is  borne  upon  one 
limb  in  the  attitude  of  rest,  in  which  the  muscles  are  thrown  out 
of  action,  tlie  knee-joint  is  locked,  but  the  insecurity  of  this  sup- 
port is  illustrated  l)y  the  school-l)oy's  trick  of  striking  the  back 
of  the  knee  with  the  hand,  when,  the  muscles  being  taken  una- 
wares, the  person  falls  to  the  ground.  This  insecurity  is  constant 
when  the  extensor  of  the  leg  is  paralyzed. 

Paralysis  limited  to  the  quadriceps  extensor  muscle  is,  how- 
ever, very  unusual.  In  almost  all  cases  some  of  the  leg  muscles 
are  involvefl  also,  and  the  brace  usually  must  serve  to  support 
the  foot  as  well  as  the  knee.  In  its  ordinary  form  such  a  l)race 
is  constructed  of  two  lateral  upright  bars,  reaching  nearly  to  the 
pubes  on  the  inner  and  to  the  trochanter  on  the  outer  side,  joined 
to  one  another  by  bands  passing  beneath  the  thigh  and  the  calf, 
and  attached  to  a  light  steel  foot-plate.  If  the  dorsal  flexors  of 
the  foot  are  paralyzed  the  ankle-joint  is  arranged  to  allow  dorsal 
flexion,  but  to  prevent  extension  beyond  the  right  angle.  If  the 
calf  muscle  is  paralyzed  a  reverse  catch  is  used,  or  the  uprights 
are  attached  directly  to  the  foot-plate  "without  a  joint  (Fig.  394) ; 
or  the  so-called  limited  joint,  allowing  only  a  few  degrees  of  motion 
in  either  direction,  is  used  (Fig.  395).  (See  Talipes.)  In  the 
treatment  of  young  children  the  joint  is  also  omitted  at  the  knee, 
the  limb  being  firmly  held  in  the  extended  position  during  the 
active  period  (Figs.  394  and  397).  This  is  of  advantage  because 
the  joint  is  the  weakest  part  of  the  brace  and  it  soon  becomes 
loose  under  the  severe  strain  to  which  it  is  subjected.  In  older  sub- 
jects a  joint  is  arranged  with  a  spring  catch,  the  l)race  being  held 
in  the  straight  position  when  the  patient  is  walking  about,  but 
allowing  flexion  when  the  sitting  posture  is  assumed.  This  is, 
of  course,  a  great  convenience  (Fig.  395).  In  fitting  the  brace 
the  lateral  bars  should  be  adjusted  to  support  the  limb  without 
uncomfortable  pressure,  and  the  joints  should  be  exactly  opposite 
the  normal  centres  of  motion.  The  thigh  and  leg  bands  should 
be  properly  fitted  to  the  contour  of  the  soft  parts  so  that  half 
the  limb  is  contained  within  them.  These  are  smoothly  covered 
with  leather,  and  the  limb  is  held  in  position  by  leather  bands 


614 


ORTHOPEDIC  SURGERY 


that  complete  the  circumference.  Other  bands  are  applied  across 
the  front  or  back  of  the  limb,  either  to  support  it  or  to  fix  it  firmly 
in  place.  In  the  ordinary  brace  without  the  joint  at  the  knee 
there  are  three  anterior  bands,  one  across  the  front  of  the  thigh, 
another  across  the  leg,  and  the  third,  a  wide  knee-cap,  supports 
the  greater  part  of  the  strain  (Fig.  397). 

Paralysis  of  the  Muscles  of  the  Hip. — The  effect  of  par- 
alysis of  the  muscles  about  the  hip  is  difficult  to  describe,  as  in 

Fig.   397 


Brace  for  coniijlete  paralysis  of  the  anterior  muscles  of  the  liiub;  before  and  after  coverinp;. 


the.se  ca.ses  many  other  muscles  are  usually  involved.  If  all 
the  muscles  are  paralyzed  the  thigh  dangles.  This  is,  however, 
very  unusual,  for  the  tensor  vaginte  femoris  almost  always  retains 
its  power  and  it  is  one  of  the  causes  of  flexion  deformity  which  is 
so  often  present  in  cases  of  this  character. 

Paralysis  of  tiie  ilio])soas  nuiscle  makes  it  impossible  for  the 
patient  to  flex  the  tliigh  directly.  If  the  adductors  are  paralyzed 
he  must  lift  I  Ik-  tliigli  with  the  hand  when  adduction  is  desired. 


DISEASES  OF  THE  NERVOUS  SYSTEM 


615 


Fin   398 


Paralysis  of  the  glutei  is  made  evident  by  the  atrophy  and  by  the 
weakness  of  the  extending  power  of  tiie  limb. 

The  distriJ)ution  of  the  paralysis  of  the  muscles  of  the  hip  may 
be  ascertained  by  placing  the  patient  in  the  recumbent  |.osture; 
the  leg  is  then  lifted  from 
the  table,  and  by  placing 
the  thigh  in  different  posi- 
tions the  ability  of  the 
patient  to  move  it  may  be 
tested,  in  older  subjects 
by  voluntary  effort,  in 
younger  ones  by  pricking 
the  part  slightly  with  a  pin. 

General  weakness  of  the 
muscles  of  the  hip  causes 
an  awkward,  insecure  gait, 
accompanied  usually  by 
outward  rotation  of  the 
limb,  and,  as  has  been 
stated,  there  is  almost  al- 
ways accompanying  par- 
alysis of  other  muscles 
of  the  extremity.  In  such 
cases  a  pelvic  band  must 
])e  attached  to  the  leg 
brace.  The  pelvic  band 
is  made  of  sheet  steel  of 
about  18  gauge,  two  inches 
wide,  fitted  to  the  pelvis, 
which  it  encircles  midway 
between  the  crest  of  the 
ilium  and  the  trochanter. 
At  this  point  it  is  attached 
to  the  brace  by  a  free  joint 
(Fig.  398).  When  the  band 
is  accurately  adjusted  and 
strapped  firmly  about  the  pelvis,  the  necessary  security  is  assured 
and  the  attitude  of  the  limb  in  walking  can  be  regulated.  If 
greater  support  is  desired  a  perineal  band  may  be  apj-licd  as 
descril)ed  in  the  chapter  on  Disease  of  the  Hip-joint. 

If  both  limbs  are  paralyzed  double  braces  mu.st  be  used.     If 
the  nuisdes  of  the  lower  part  of  the  back  are  much  wcakenetl 


Leg  brace,  with  pelvic  band.  Double  uprights. 
No  joint  at  knee.  For  paralysis  of  the  anterior 
thigh  and  leg  muscles. 


616  on  TH  OPE  Die  SUBGERY 

the  pehic  band  may  be  replaced  by  a  corset  or  some  form  of  back 
brace.     Fortunately  these  cases  are  luicommon. 

Paralytic  Scoliosis. — Paral\1:ic  scoHosis  requires  the  support 
of  corsets  or  braces  as  a  rule,  such  as  are  used  in  the  treatment 
of  other  forms  of  distortion  of  the  back.     (See  Lateral  Curvature.) 

Paralysis  of  the  Arji. — Paralysis  of  the  arm  is  comparatively 
uncommon,  and  treatment  is  rarely  demanded. 

In  some  instances  a  shoulder  support  may  be  of  service  or  a 
brace  to  hold  the  arm  at  a  right  angle  if  the  biceps  is  paralyzed. 
If  the  muscles  of  the  scapula  retain  their  power  the  operation  of 
arthrodesis  might  be  of  service  in  fixing  the  dangling  joint,  and 
the  same  operation  might  be  useful  at  the  elbow.  It  is,  of  course, 
evident  that  one  of  the  lower  extremities,  although  hopelessly 
weakened,  may  be  braced  so  that  it  may  serve  as  a  simple  prop 
to  bear  weight,  but  as  the  function  of  the  arm  is  quite  different, 
extensive  paralysis  of  its  muscles  makes  it  practically  useless  to 
the  individual. 

Operative  Treatment.  The  Reduction  of  Deformity. — In  a 
large  proportion  of  the  cases  of  anterior  poliomyelitis  the  patients 
are  not  seen  by  the  orthopedic  surgeon  imtil  months  or  years 
have  elapsed  since  the  original  attack.  They  are  then  brought 
for  treatment  because  of  secondary  deformity  often  of  an  extreme 
degree.  At  least  half  of  the  cases  of  talipes  are  due  to  this 
cause,  and  with  the  deformity  of  the  foot  are  often  combined  other 
distortions  varying  in  degree  with  the  extent  of  the  paralysis. 
]\Iany  of  the  patients  hobble  about  on  a  distorted  foot,  others 
use  crutches,  and  in  a  smaller  number  the  only  method  of  loco- 
motion is  creeping  on  all-fours.  In  the  cases  in  which  the  patient 
has  habitually  used  crutches  allowing  the  paralyzed  limb  to 
"dangle,"  there  is  usually  marked  flexion  at  the  three  joints. 
'^I'he  thigh  is  flexed  upon  the  pelvis,  the  leg  is  flexed  upon  the 
thigh,  and  the  foot  hangs  downward  and  inward  (plantar  flexed) 
in  an  attitude  of  equino  varus. 

However  extreme  the  paralysis  of  a  lower  extremity  may  be, 
the  limb  may  be  made  useful  as  a  prop  when  properly  braced; 
this  prop  will  enable  the  patient  to  dispense  with  the  use  of  crutches 
and  thus  free  the  arms  from  unnecessary  work.  Even  if  both 
limbs  are  paralyzed  they  may  at  least  serve  as  supports  to  enable 
the  patient  to  stand  erect  and  to  propel  himself  with  the  aid  of 
crutches.  If  a  limb  has  been  disused  for  a  long  time,  the  atrophy 
is  usually  extreme,  the  bones  are  fragile,  and  the  growth  has  been 
greatly  retarded  as  ccmipared  with  those  limbs  in  which  deformity 


DISEASES  OF  THE  NERVOUS  SYSTEM  617 

has  been  prevented  and  in  wliicli  the  weight  of  the  l)ody  has  been 
sustained  in  functional  use.  In  this  class  of  cases  the  first  step 
must  be  the  reduction  of  deformity;  the  foot  must  be  brought 
to  a  right  angle  with  the  leg,  the  limb  must  be  brought  to  the 
straight  line,  and  the  flexion  at  the  hip  must  be  overcome  in  onler 
to  enable  the  patient  to  stand  erect  without  bending  the  spine 
forward  in  compensatory  lordosis. 

Acquired  deformity  of  the  foot  is  far  less  resistant  than  is  the 
congenital  form,  and  by  tenotomy  and  the  proper  application  of 
force  it  may  be  readily  straightened,  usually  at  one  sitting. 

The  flexion  contraction  at  the  knee  may  be  overcome  also  by 
careful  and  persistent  manual  stretching  comlnned,  if  necessary, 
with  division  of  the  contracted  tissues  on  the  posterior  aspect  of 
the  joint.     (See  page  41S.) 

The  flexion  deformity  at  the  hip  is  usually  fixed  by  the  con- 
traction of  the  tissues  about  the  anterior  superior  spine  of  the 
ilium,  including  the  tensor  vagina'  femoris  muscle,  which  is  rarely 
paralyzed.  These  tissues,  together  with  the  fascia,  may  l)e  divided 
subcutaneously,  or  by  open  incision  if  necessary;  after  which 
the  deformity  may  be  reduced  by  gradual  forcible  extension  of  the 
thigh  while  the  pelvis  is  fixed  by  flexing  the  other  limb  upon  the 
body.  When  the  contraction  deformities  are  overcome  lateral 
deviation  at  tlie  knee  is  corrected,  if  it  be  present,  in  the  same 
manner,  and  the  bony  points  having  been  carefully  protected  by 
padding  a  long  spica  plaster  bandage  is  applied  to  fix  the  limb. 

The  lesser  degrees  of  deformity  may  be  reduced  by  other 
means,  for  example,  by  repeated  applications  of  plaster  bandages 
under  slight  corrective  force,  or  by  manipulation,  or  by  braces 
and  bandaging. 

Paralytic  knock-knee  may  be  corrected  by  the  Thomas  knock- 
knee  brace,  and  this  brace  when  attached  to  a  pelvic  band  is  a 
useful  form  of  support  in  the  routine  treatment  of  paralysis  of 
the  leg  (Fig.  378). 

The  Thomas  caliper  knee  brace  is  another  cheap  and  useful 
support.  It  is  of  special  service  when  there  is  flexion  or  lateral 
deformity  of  the  limb    (Fig.  282). 

When  distortion  has  been  overcome  and  when  functional  use 
has  been  made  possible  by  proper  support,  the  development  of 
active  muscles  which  have  been  thrown  out  of  use  by  the  distor- 
tions, and  of  those  in  which  part  of  the  nuiscular  substance  has 
been  retained,  is  surprising.  In  many  of  these  cases  the  distor- 
tions wliicli  developed  during  the  tcnijxM'ai'y  j);ir;ilysis  have  alone 


618 


ORTHOPEDIC  SURGERY 


prevented  recovery,  antl  this  latent  power  may  be  revived  even 
after  years  of  disuse.  Thus  in  many  instances  prognosis  is 
impossible  until  the  deformities  have  been  corrected  and  imtil 
the  limb,  properly  supported,  has  been  enabled  to  resume  its 
function. 

Tendox  Trax.splaxtatiox. — This  operation  is  best  adapted 
to  the  treatment  of  distortions  of  the  foot  caused  by  paralysis  of 
the  muscles  of  the  leg,  and  the  procedure  is  described  at  length 
in  that  section. 


Fin.   399 


Paralysis  of  the  left  dolioid  nm-il',  -hnwing  the  elevation  of  the  shoulder  when  the 
patient  attempts  t(j  abduct  the  arm.      (See  Fig.  400.) 

Hoffa's  Operatiox  fok  Paralyhls  of  the  Deltoid  Muscle. 
— One  of  the  most  useful  operations  of  this  class  is  the  transplanta- 
tion of  the  trapezius  muscle  for  paralysis  of  the  deltoid.  In  cases 
(  f  (his  class  there  is  disabling  laxity  or  even  subluxation  at 
the  articulation,  and  the  exaggerated  elevation  of  the  shoulder 
when  the  patient  attempts  to  raise  the  arm  makes  the  disability 
very  noticeable  (Fig.  399). 

A  Ijroad  Hap  of  skin,  its  convexity  over  the  upper  cpiarter  of 
the  deltoid    muscle,  is    nti.scd    exposing   the    trapezius.     This    is 


DISEASES  OF  THE  NERVOUS  SYSTEM  619 

thoroughly  separated  from  its  attachment  to  tlie  spine  of  the 
scapular  and  to  the  chivicle.  The  arm  is  then  alxhicted  and  the 
flap  of  muscle,  made  tense,  is  sewed  with  numerous  silk  sutures 
to  the  atrophied  deltoid  and  underlying  capsule  of  the  joint.  The 
skin  wound  is  then  closed  and  the  limb  is  fixed  in  complete 
abduction  by  means  of  a  plaster  bandage.  This  attitude  should  be 
retained  for  about  two  months.  Afte  ward  massage  and  exercises 
should    be   employed.      The  humerus  is  usually  held  securely,  a 

Fio.  41)0 


Illustrating  the  improvement  in  the  range  of  abduction  obtained  by  transplantation 
of  the  trapezius  muscle.     The  line  of  the  incision  is  shown. 

certain  power  of  abduction  is  restored,  and  the  functional  ability 
often  greatly  increased  (Figs.  399  and  400). 

Tr.\nsi'Lantation  of  the  S.\kt()1Uus  Mi'SCLK. — In  cases  in 
which  the  quadriceps  extensor  muscle  is  paralyzed  its  function 
may  be  in  part  restored  by  transplantation  of  the  Sartorius, 
as  suggested  by  (ioldthwait.  A  slightly  curved  incision  is  made 
from  the  patella  inward  and  ui)ward    to  the  middle  third  of  the 


620  ORTHOPEDIC  S UBGEB Y 

thigh.  The  Sartorius  is  exposed,  divided  near  its  insertion  and 
thoroughly  separated  from  the  surrounding  parts.  Its  extremity 
is  then  inserted  into  an  opening  made  in  the  tendinous  expansion 
of  the  quadriceps  muscle,  to  which  and  to  the  patella  it  is  firmly 
attached.  The  extended  position  should  be  retained  for  several 
months.  In  favorable  cases  a  useful  degree  of  power  of  extension 
is  supplied.  . 

Paralysis  of  the  muscles  of  the  arm  and  hand  is  comparatively 
unusual.  The  operation  of  tendon  shortening  combined  with 
transplantation  of  the  tendons  of  one  or  more  active  muscles 
may  be  of  ser\dce  in  the  treatment  of  ^\Tist-drop,  and  opportunities 
may  suggest  themselves  in  other  situations  whenever  it  is  possible 
to  utilize  the  muscular  power  to  better  advantage. 

Arthrodesis. — x\s  has  been  stated  of  tendon  transplantation, 
arthrodesis  is  of  greatest  ser^'ice  at  the  ankle-joint,  where  it  may 
serve  to  fix  the  foot  at  a  right  angle  ^vith  the  leg.  (See  Talipes.) 
In  exceptional  cases  arthrodesis  or  excision  at  the  knee  may  be 
advisable  in  the  older  patients,  but  in  young  subjects  the  strain 
upon  the  long,  weak  lever  formed  by  the  two  bones  will  almost 
always  induce  deformity.  Arthrodesis  at  the  hip  might  be  of 
sernce  in  cases  of  complete  paralysis  of  the  pelvic  muscles.  The 
operation  is  performed  as  for  arthrotomy  in  the  treatment  of  con- 
genital displacement  of  the  hip  (see  page  544),  except  that  the 
cartilage  is  thoroughly  removed  from  the  head  of  the  femur  and 
from  the  acetabulum.  A  short  spica  plaster  support  should  be 
worn  until  union  is  firm. 

Arthrodesis  at  the  shoulder  may  be  of  service  when  the  supporting 
muscles  are  paralyzed.  The  method  of  opening  the  joint  is  des- 
cribed on  page  489. 

Arthrodesis  at  the  elbow  and  wrist  may  be  of  service  in  assuring 
an  improved  attitude.  Whenever  possible  the  operation  should 
be  reinforced  l)y  ten(h)n  or  muscle  transplantation. 

Osteotomy. — In  rare  instances,  particularly  in  the  extreme 
deformities  in  the  adult,  osteotomy  of  the  femur  at  the  hip 
or  knee  may  be  necessary  in  order  to  overcome  resistant  dis- 
tortion. 

Nervp:  GitAFTiNG. — A  number  of  operations  have  been  per- 
formed recently  with  the  aim  of  restoring  nniscular  power  in 
paralyzed  muscles  by  uniting  the  inactive  nerve  with  one  which  is 
still  in  comiiumication  with  the  nerve  centres.  Some  encouraging 
results  hiivo  been  rejxjrted,  l)Ut  they  are  far  from  convincing. 
It   hardly  seems  likely  that  <i    nerve  that    has  been  inactive  for 


DISEASES  OF  THE  NERVOUS  SYSTEM  621 

years  would  retain  a  sufficiently  normal  structure  to  take  up  its 
function  again  even  if  the  union  with  another  nerve  trunk  were 
perfect/ 

Recapitulation  of  Treatment. — This  consists  in  support  and 
electrical  stimulation  of  the  muscles  during  the  period  of  recovery, 
together  with  a  suitable  brace  to  hold  the  limb  in  the  best  possible 
position  for  usefulness  when  the  final  extent  of  the  paralysis  has 
become  evident.  With  the  support  any  treatment  tiiat  will  im- 
prove the  nutrition  of  the  part  is  of  service;  massage  and  muscle- 
beating  are  of  special  value.  The  limb  in  which  the  circulation 
is  deficient  should  l)e  protected  from  the  cold  by  proper  covering, 
and  its  nutrition  may  be  improved  by  the  direct  application  of 
heat,  the  hot-air  or  hot- water  bath  both  being  useful.  Above  all 
else,  functional  use,  which  is  made  possible  by  apparatus,  is  of  the 
first  importance  in  preserving  and  stimulating  whatever  muscidar 
power  remains;  and  special  gymnastic  exercises  to  this  end  may 
be  employed  if  practicable.  The  prevention  of  deformity  during 
the  growing  period  is  of  great  importance.  Every  morning  and 
night  the  joints  of  the  paralyzed  part  should  be  passively  moved 
to  the  normal  limits  in  all  directions  in  order  to  prevent  the  gradual 
limitation  of  the  range  of  motion  which  is  the  first  indication  of 
the  deformity.  Lateral  deviation  of  the  limb  or  foot  may  be 
prevented  by  passive  manipulation  and  by  careful  adjustment 
or  modification  of  the  support.  Braces  should  be  strong  and  as 
simple  as  may  be  in  construction.  Elastic  bands  and  springs. 
applied  with  the  design  of  replacing  paralyzed  muscles,  are  of 
little  practical  use,  since  they  are  ineffective  in  action,  difficult 
to  adjust,  and  easily  disarranged.  The  parent,  when  treatment 
is  begun,  must  be  impressed  with  the  fact  that  a  brace  must  be 
strong  enough  to  serve  its  purpose  even  though  its  weight  be 
objectionable;  that  its  period  of  usefulness  is  limitetl,  and  that  it 
must  be  replaced  when  it  is  outgroAvn;  that  the  breaking  of  a  brace 
from  time  to  time  is  unavoidable,  and  that  such  accidents,  in  so 
far  as  they  are  evidences  of  the  functional  acti^^ty  of  the  patient, 
are  favorable  indications. 

Careful  supervision  of  the  patient,  even  though  the  weakness 
is  not  great,  will  be  necessary  during  the  period  of  growth.  The 
contrast  between  the  development  and  synunetry,  the  nuiscular 
power  and  practical  utility  of  a  liml)  that  has  received  this  eare 
and  supervision,  and  one  tliat  lias  l)e  n  neglected,  is  suliiciently 

'  Spitzy,  Amer.  Jour.  Ortli.  Surgery,  August,  1904. 


622  ORTHOPEDIC  SURGERY 

striking  to  impress  anyone    with    the   necessity    for  this  tedious 
and  apparently  never-ending  treatment. 

Thus,  in  this  as  in  other  chronic  diseases  and  disabihties  the 
character  and  the  duration  of  the  treatment,  its  object,  and  the 
final  results  that  one  may  expect  to  attain  by  it,  should  be  ex- 
plained to  the  parents  when  the  care  of  the  patient  is  undertaken. 


CHAPTEK    XVIII. 

DISEASES  OK  THE  NERVOUS  SYSTEM   (Cominited). 

Cerebral  Paralysis  of  Childhood— Spastic  Paralysis. 

Cerebral  paralysis  or  palsy  is  in  orthopedic  jH-acticc  second 
only  in  frequency  and  importance  to  anterior  poliomyelitis.  It 
is,  however,  entirely  difi'erent  in  its  distribution  and  in  its  effects. 
It  is  a  form  of  disability  that  is  characterized  by  motor  weakness, 
by  stiffness  and  loss  of  control,  rather  than  by  paralysis.  It 
affects  entire  members  and  it  results  in  atrophy,  contractions,  and 
deformity. 

It  may  involve  half  the  body,  hemiplegia. 

It  may  be  limited  to  the  lower  extremities,  paraplegia. 

It  may  involve  both  the  upper  and  lower  extremities,  diplegia. 

In  rare  instances  but  one  extremity  is  affected,  monoplegia. 

Distribution. — In  451  cases  of  cerebral  paralysis  analyzed  by 
Peterson,^  332  were  of  the  hemiplegic  type,  73  were  of  the 
diplegic  type,  and  46  were  of  the  paraplegic  type.  In  121  cases 
observed  at  the  Hospital  for  Ruptured  and  Crippled,  63  were 
paraplegic  or  diplegic  and  58  were  hemiplegic.  The  liemiplegic 
form  of  paralysis  is  usually  acquired;  the  diplegic  and  parapk^gic 
forms  are  usually  congenital. 

Etiology  and  Pathology. — Cerebral  paralysis  may  be  divided 
into  two  classes — the  congenital  and  the  accjuired. 

Congenital  Paralysis. — Paralysis  of  intrauterine  origin  may  ))e 
the  result  of  maldevelojiment  or  injury  or  a  secondary  effect  of 
intercurrent  disease  of  the  motlier.  Paralysis  caused  l)y  injury 
at  birth  is  usually  the  result  of  rupture  of  bloodvessels  of  the 
meninges  due  to  prolonged  labor  or  to  the  pressure  of  instru- 
ments. 

Acquired  Paralysis. — Ac(juired  paralysis  may  be  duv  to  hemor- 
rhage, embolism,  thrombosis,  or  to  disease.  Sachs"  ])resents  the 
following  classification  of  causes  and  effects: 

'   American  Text-book  of  Diseases  of  Children. 
2    Sachs,  Nervous  Diseases  of  Children. 


624 


OR  THO PEDLC  S  UR  G ER  Y 


Paralysis  of  Intrauterine  Origin. 

Large  cerebral  defects — true  porencephaly. 

Hemorrhages  of  intrauterine  origin — softening. 

Agenesis  corticalis. 
Paralysis  Occurring  during  Labor. 

Meningeal  hemorrhage^ — very  seldom  intracerebral.  Resulting 
conditions:  meningoencephalitis  chronica;  sclerosis;  cysts;  atro- 
phies; porencephalies. 

Fig.   401 


Congenital  cerebral  diplegia  (idiocy). 

Paralysis  Acquired  after  Birth. 

L  Meningeal  hemorrhage — very  seldom  intracerebral.  Em- 
bolism: thrombosis  in  marantic  conditions,  and  occasionally  from 
syphiUtic  cndoarteritis.  Results  of  these  vascular  lesions:  cysts; 
softening;  atrophy;  sclerosis,  diffuse  and  lobar. 

2.  Chronic;  meningitis. 

y>.  IIydroce[>haliis. 

4,  Primary  encephalitis  (Striimpell), 


DISEASES  OF  THE  NERVOUS  SYSTEM 


625 


General  Symptoms.  Motor. — The  effect  of  the  lesion  of  the 
brain  and  of  the  secondary  changes  in  the  cord  is  to  impair  the 
voluntary  control  of  the  limbs  supplied  from  the  affected  area, 
and  at  the  same  time  the  inhibition  of  the  higher  centres  is  im- 
paired or  lost.  Thus,  together  with  the  loss  of  power,  there  is 
usually  a  corresponding  exaggeration  of  the  reflexes  causing  a 
spastic  rigidity  of  the  limbs.  This  induces  distortion,  which 
finally  becomes  fixed  by  the  adaptive  changes  in  the  tissues.     As 

Fig.  402 


Spastic  paraplegia. 

the  centres  for  the  nutrition  of  the  paralyzed  parts  are  not 
involved,  the  muscles  do  not  waste  and  the  circulation  is  but  little 
affected.  Thus  the  atrophy  as  compared  "u-ith  paralysis  of  spinal 
origin  (anterior  poliomyelitis)  is  comparatively  slight,  and  this, 
together  with  the  retardation  of  growth,  is  due  rather  to  the  general 
effects  of  the  disease  and  to  the  loss  of  function  than  to  the  direct 
influence  of  the  nervous  lesion. 

40 


626  ORTHOPEDIC  SURGERY 

Mental. — In  this  form  of  paralysis  the  lesion  is  of  the  brain, 
and  the  direct  injury  of  its  structure  and  the  interference  with  its 
development  is  likely  to  cause  mental  impairment.  This  mental 
impairment  is  usually  more  marked  in  the  paraplegic  or  diplegic 
than  in  the  hemiplegic  form,  because  in  the  latter  but  haK  the 
brain  is  mvolved,  and  because  the  injury  or  disease  occurs  at  a 
later  period  of  its  development.  So,  also,  the  mental  development 
is  usually  less  interfered  with  in  the  paraplegic  than  in  the  diplegic 
tA-pe.  For,  although  both  hemispheres  were  involved,  yet  the 
recovery  of  power  in  the  arms  shows  that  the  mjury  was  less  exten- 
sive than  when  the  weakness  persists  in  one  or  both  of  the  upper 
extremities. 

It  is  estimated  that  in  50  per  cent,  of  the  hemiplegic  cases  the 
patients  are  feeble-minded,  although  comparatively  few  (13  per 
cent.)  are  idiotic.  In  the  paraplegic  and  diplegic  forms  of  par- 
alysis about  70  per  cent,  of  the  patients  are  feeble-minded,  and 
from  40  to  50  per  cent,  are  idiotic.     (Sachs.) 

Epilepsv  is  an  accompaniment  of  about  45  per  cent,  of  all 
forms  of  cerebral  paralysis,  and  m  20  per  cent,  of  the  cases  athetoid 
or  associated  movements  in  the  paralyzed  parts  persist.    (Peterson.) 

Congenital  Weakness  and   Paralysis. 

The  congenital  form  of  cerebral  paralysis  is  often  seen  in 
orthopedic  clinics,  because  the  effect  of  the  lesion  of  the  brain 
in  retarding  physical  development  first  attracts  the  attention  of 
the  mother.  Thus,  infants  are  brought  for  examination  because 
they  are  unable  to  sit  or  stand  at  the  usual  time.  In  certain 
instances  the  cause  of  the  physical  weakness  is  simple  idiocy.  In 
such  cases  the  vacant  expression,  the  inability  of  the  child  to  recog- 
nize even  its  mother,  the  extreme  weakness,  and  the  absence  of  the 
spastic  rigidity  of  the  limbs  will  make  the  diagnosis  clear. 

In  another  class  of  cases  the  wealsjiess  appears  to  be  caused 
simply  by  retarded  cerebral  development.  The  patient  is  apathetic 
and  weak,  but  there  is  no  evidence  of  paralysis  and  the  comparative 
intelligence  of  the  patient  distinguishes  this  type  from  the  idiotic 
class. 

In  the  characteristic  form  of  cerebral  paralysis  as  seen  in  early 
life  the  child  may  be  idiotic,  or  simply  apathetic,  or  fairly 
normal  in  intelligence,  but  it  is  always  weak,  and  in  the  sitting 
posture  the  spine  is  usually  bent  backward  into  a  long,  more  or 
less  rigid  curve.     It  makes  no  effort  to  stand,  and  wlien  placed 


DISEASES  OF  THE  NERVOUS  SYSTEM  627 

in  tlie  erect  posture  it  will  be  noticed  that  the  thighs  are  usually 
pressed  closely  against  one  another  and  that  the  feet  are  extended. 
The  limbs  are  "stiff."  There  is  a  peculiar  resistance  to  flexion 
at  the  extended  joints,  which  slowly  gives  way  under  steady 
pressure.     This  is  the  characteristic  spastic  rigidity  (Fig.  401). 

Deformities. — ^These  children  usually  begin  to  stand  and  to 
walk  at  about  the  third  year  or  later  with  an  awkward,  shuffling 
gait;  the  limbs  are  usually  flexed,  adducted,  and  rotated  inward; 
the  knees  touch  one  another  or  the  legs  may  be  crossed,  while 
the  feet  tin-n  inward  in  a  persistent  attitude  of  slight  equinovarus. 
The  equilibrium  is  very  easily  disturbed,  partly  because  of  tlie 
deformities  and  partly  because  of  direct  lesion  of  the  brain.  In 
the  majority  of  the  congenital  cases  the  paralysis  is  paraplegic  in 
its  distribution;  perhaps  15  per  cent,  are  of  the  hemiplegic  variety, 
and  in  a  somewhat  larger  number  the  paralysis  is  diplegic  in 
distribution  (Fig.  401). 

It  has  been  stated  that  the  typical  deformity  of  the  foot  was 
equinovarus,  but  in  older  subjects  who  have  walked  about  in  the 
attitude  of  flexion  at  the  hips  and  laiees  there  may  be  an  accom- 
modative distortion  of  the  foot  toward  valgus,  or  even  to  an  ex- 
treme degree  of  calcaneovalgus. 

x^s  has  been  stated,  in  a  certain  number  of  cases  the  intelli- 
gence is  not  impaired,  but  more  often  the  patients  are  distinctly 
feeble-minded.  They  are  very  nervous,  easily  startled,  emotional, 
arid  are  often  imable  to  speak  distinctly,  yet  it  is  interesting  to 
note  that  this  peculiar  emotional  excital)ility  often  passes  for  an 
extreme  degree  of  brightness  of  intellect  and  (juickness  of  per- 
ception. In  fact,  ])a rents  often  remain  unconvinced  that  the 
child  is  lacking  in  mental  power  until  it  reaches  an  age  when 
comparison  with  other  children  makes  this  conclusion  inevitable. 

Acquired  Paralysis. 

As  in  adidt  life,  the  common  form  of  acquired  cerebral  par- 
alysis in  childhood  is  hemiplegia.  About  two-thirds  of  all  the 
cases  occur  hi  the  first  three  years  of  life;  and  in  about  20  per 
cent,  of  these  the  affection  of  the  brain  is  a  complication  of  infec- 
tious disease.  The  onset  is  usually  sudden,  ami  is  accompanied 
in  the  majority  of  cases  by  fever,  convulsions,  and  loss  of  con- 
sciousness. When  the  child  regains  consciousness  the  paralysis 
of  the  arm  and  leg  is  at  once  evident,  and  in  about  20  per  cent, 
of  the  cases  the  face  is  paralyzed  a,lso. 


628 


OB THOPEDIC  SURGERY 


Fig    403 


Deformities. — At  first  the  paralysis  is  a  simple  powerlessDess, 
but  soon  the  exaggeration  of  the  reflexes  is  evident.  As  has 
been  stated,  there  is  a  loss  of  voluntary  power  and  an  increase  of 
the  reflexes  or  "stiffness"  of  the  paralyzed  members.  They  are 
no  longer  competent  to  assume  the  more  difficult  attitudes  and 
functions,  and  these  are  replaced  by  those  that  are  simpler;  thus 
flexion  becomes  habitual. 

In  t^-pical  hemiplegia  the  foot  is  plantar  flexed  and  adducted. 
The  leg  is  flexed  on  the  thigh  and  the  thigh  on  the  trunk,  and 

with  the  flexion  adduction  is  usually 
combined.  The  arm  is  held  against  the 
thorax,  the  forearm  is  flexed  upon  the 
arm  in  an  attitude  midway  between  pro- 
nation and  supination.  The  hand  is 
flexed  upon  the  arm  and  inclined  toward 
the  ulnar  side  and  the  fingers  are  clasped 
over  the  adducted  thumb  (Fig.  403). 

Disability. — ^The  loss  of  power  is  not 
absolute;  in  most  instances  the  patient 
is  able  to  walk  with  an  exaggerated  limp, 
dragging  the  stiffened  and  distorted  limb, 
which  serves  as  a  prop  rather  than  as 
'  an  active  support.  So,  also,  the  control 
of  the  upper  extremities  is  in  part  re- 
tained; the  patient  is  able  to  abduct  the 
arm,  to  partly  extend  the  forearm,  some- 
times to  extend  the  fingers  and  to  abduct 
the  thumb,  but  the  power  to  dorsiflex  the 
hand  and  at  the  same  time  to  extend 
the  fingers  is  not  usually  retained  in  a 
case  of  this  character. 

Loss  of  Growth.— The  growth  of  the 
patient  as  a  whole  is  usually  retarded  to 
a  certain  extent  by  the  lesion  of  the  brain, 
'^i'here  is  in  addition  a  certain  degree  of 
inequality  in  the  growth  of  the  two  halves 
of  the  body.  This  inequality  is  more 
marked  in  the  upper  than  in  the  lower 
extremity.  Shortening  to  the  extent  of 
an  inch  in  the  lower  extremity  is  not 
usually  exceeded,  but  the  growth  of  the  arm  and  hand  may  be  very 
markedly  checked.     This  disproportionate  loss  of  growth  in  the 


Acquired  cerebral  hernir)leKia. 


DISEASES  OF  THE  NERVOUS  SYSTEM  629 

upper  over  the  lower  extremity,  although  it  may  be  explained  in 
part  by  the  situation  of  the  lesion  of  the  brain,  depends  more  directly 
upon  the  interference  with  function.  The  lower  extremity  is  rarely 
disabled  to  an  extent  that  prevents  its  use  in  locomotion,  conse- 
quently its  nutrition  is  preserved;  whereas,  the  same  degree  of 
paralysis  of  the  arm  utterly  unfits  it  for  its  more  difficult  functions 
and  it  becomes  a  useless  appendage.  With  the  disuse  of  function 
there  is  a  corresponding  diminution  of  nutrition  and  a  consequent 
atrophy  and  loss  of  growth. 

Extreme  deformity  and  disability,  as  in  the  type  described,  are 
rather  unusual.  In  many  instances  there  is  almost  complete 
recovery  from  the  paralysis,  only  an  awkwardness  and  slowness 
of  movement,  combmed  with  an  increase  of  reflexes  and  a  slight 
hemiatrophy  of  the  body  exists.  In  some  cases  a  slight  degree 
of  equinus  is  the  only  deformity;  in  others  weakness  of  the  arm 
may  persist,  although  complete  control  of  the  lower  extremity 
has  been  regained. 

The  final  effect  of  the  paralysis  is  almost  always  more  marked 
in  the  upper  than  in  the  lower  extremity;  thus,  when  contrac- 
tions and  deformities  of  the  lower  extremity  are  present  the  arm 
and  hand  are  often  practically  disabled. 

Treatment.  1.  Hemiplegia. — The  treatment  from  the  ortho- 
pedic standpoint  consists  in  stimulatmg  the  nutrition  of  the 
paralyzed  parts,  in  preventing  deformity,  and  in  improving  the 
functional  ability.  The  results  of  treatment  are,  of  course,  very 
greatly  influenced  by  the  mental  condition  of  the  patient.  If 
the  mental  power  is  not  impaired  one  may  count  upon  the  efforts 
of  the  patient  for  aid ;  whereas,  if  the  patient  is  idiotic  there  is  but 
little  encouragement  for  active  treatment.  If  the  patient  is  seen 
before  the  secondary  contractions  have  appeared,  deformity  may 
be  prevented  in  great  degree  by  regular  massage  and  by  passive 
movements  in  the  directions  opposed  to  the  habitual  positions.  If 
the  spastic  contraction  is  slight  a  light  jointed  leg  brace  attached 
to  a  pelvic  band  may  be  used.  By  this  m^ans  the  movements  are 
controlled  and  the  excessive  expenditure  of  nervous  energy  neces- 
sary to  guide  the  limb  may  be  lessened.  If  the  support  is  sup- 
plemented by  massage  and  regular  exercises  the  control  of  the 
limb  may  be  greatly  improved. 

In  many  instances  the  patients  are  not  seen  until  late  child- 
hood, when  the  deformities  have  become  fixetl.  The  foot  is 
usually  turned  inward  antl  downward  (equinovarus) ;  there  is 
flexion  at  tlie  knee  and  often  flexion  and  adduction  at  tlie  hip, 


630  OBTHOPEDIC  SURGERY 

the  resistance  of  the  contractions  bemg  dependent  upon  the  dura- 
tion of  the  deformity.  In  such  cases  the  distortions  must  be 
corrected  by  force  and  by  division  of  more  resistant  tissues,  in- 
chiding  often  the  tendo  Achilhs,  the  plantar  fascia,  and  m  many 
instances  the  hamstrings  and  the  adductors  of  the  hip.  The 
hmb  is  then  fixed  in  a  phister-of-Paris  bandage  for  a  sufficient 
time  to  overcome  the  more  direct  tendency  to  deformity.  In 
correctmg  hemiplegic  or  paraplegic  deformity  one  should  be 
particular  to  overcome  resistant  contraction  at  the  knee  before 
dividmg  the  tendo  Achillis,  for  if  the  patient  is  allowed  to  walk 
afterward  with  a  flexed  knee  the  foot  may  assume  the  calcaneus 
deformity.  As  additional  precaution  the  foot  at  the  time  of  an 
operation  should  be  fixed  at  a  right  angle  with  the  limb ;  not  over- 
corrected  as  is  usual.  Wlien  the  bandage  is  removed  a  brace  is 
of  service  in  guidmg  the  limb,  and  regular  massage  and  forcible 
passive  movements  together  with  proper  exercises  should  be 
employed  whenever  practicable.  In  this  class  of  cases  the  deformi- 
ties may  be  overcome  in  most  instances,  but  there  is  a  tendency 
toward  flexion  at  the  knee,  and  stiffness  and  awkwardness  in 
movement  usually  persist. 

In  many  of  the  milder  hemiplegic  cases  the  only  deformity  is 
of  the  foot.  This  should  be  treated  ])y  division  of  the  tendo 
Achillis  and  l)y  support  for  a  time  until  the  deformity  habit  has 
disappeared. 

Tendon  Transplantation. — If  the  arm  is  but  slightly  affected 
proper  exercises  will  greatly  improve  its  ability.  In  the  more 
extreme  cases,  in  which  the  fingers  a  e  clasped  over  one  another, 
treatment  is  of  little  avail.  In  another  class,  in  which  the  patient 
has  the  power  of  extending  the  fingers  only  when  the  wrist  is  flexed, 
the  power  of  dorsiflexion  may  be  restored  or  improved  by  trans- 
planting the  flexors  of  the  carpus  on  the  radial  and  ulnar  border  to 
the  extensors,  wliicli  have  been  overlapped  and  shortened  to  tlie 
prooper  extent.  These  tendons  may  be  exposed  by  lateral  incisions, 
and  may  be  attached  to  the  dorsal  tendons  by  passing  them  about 
the  border  of  the  radius  and  of  the  ulna,  or  the  tendons  may  be 
elongated  by  silk,  which  may  be  insertetl  directly  to  the  meilian  sur- 
face of  the  tarsus  or  metatarsus.  In  such  instances  one  hopes  that 
fibrous  tissue  will  be  deposited  about  the  artificial  tendon  and 
finally  replace  it.  In  otjier  instances  the  two  tendons  have  been 
pushetJ  through  an  opening  in  tlie  interosseous  membrane  to  the 
dorsal  surface  of  the  wrist,  and  there  united  with  the  tendons  of 
the  extensors  of  the  fingers.     The  results  of  these  operations  as 


DISEASES  OF  THE  NERVOUS  SYSTEM 


631 


far  as  improving  the  attitude  is  concerned  are  usually  good.  The 
transplantation  of  other  tendons  may  be  of  service,  but  the  opera- 
tion is  limited  in  usefulness  for  the  reasons  state<l/  Athetoid  move- 
ments of  the  hand  and  arm  may  be  relieved  somewhat  by  prolonged 
fixation  in  a  plaster  bandage,  or  by  arthrodesis  at  the  wrist-joint. 


Fig.   404 


Cerebral  paraplegia,  second  stage  in  treatment,  the  long  replaced  by  the  short  spica.  This 
patient,  at  the  age  of  eight  years,  was  unable  to  stand  without  assistance.  The  spastic 
contractions  and  deformities  were  overcome  by  tenotomies  and  by  force,  and  a  double 
long  spica  bandage  was  applietl.  This  was  worn  for  eight  months.  It  wa3  then  replaced 
by  the  bandage  shown  in  the  illustration.  Six  months  later  this  was  removed.  There  is 
at  present  no  deformity,  and  the  child  walks  fairly  well. 

2.  Paraplegia. — The  treatment  of  spastic  paraplegia  is  much 
more  difhcult  than  that  of  hemiplegia,  because  the  disability  is 
very  much  greater  and  because  the  mental  impairment  is  usually 
more  marked. 

In  general,  the  treatment  in  infancy  is  by  massage  anil  by 
manipulation.     When  the  child  shows  a  desire  to  walk  an  at- 

^  Townsend,  Transactions  American  Orthopedic  Association,  1900,  vol.  xiii. 


632  ORTHOPEDIC  SURGERY 

tempt  should  be  made  to  relieve  the  spastic  contractions.  In 
certain  instances  complete  correction  of  all  deformities,  followed 
by  prolonged  fixation  of  each  joint  in  the  overcorrected  attitude, 
may  be  of  service  (Fig.  40-1).  This  may  be  combined  with  mul- 
tiple tenotomies  if  the  contractions  are  more  resistant.  The 
advantage  of  tenotomy,  aside  from  the  simple  correction  of  de- 
formity, is  that  by  elongation  of  the  tendon  the  response  to  the 
exaggerated  motor  impulses  is  lessened  and  an  opportunity  for 
more  effective  control  is  afforded.  The  beneficial  effect  of  com- 
plete division  of  contracted  parts  in  checking  spasmodic  contrac- 
tions is  very  marked  in  older  patients. 

Tendon  Transportation. — Transplantation  of  tendons  from 
the  flexor  to  the  extensor  aspect  of  the  limb  to  overcome  per- 
sistent flexion  of  the  knee  may  be  of  service  in  certain  cases. 
According  to  the  method  of  Lange,  the  tendons  are  exposed  by 
incisions  on  the  lower  lateral  aspects  of  the  knee.  They  are 
then  carried  forward  beneath  the  skin  and  are  attached  to  the 
insertion  of  the  quadriceps  extensor  tendon,  which  is  exposed  by 
a  median  incision.  The  actual  insertion  is  usually  made  by  a 
strong  cord  of  silk  prolonged  from  the  extremity  of  each  tendon. 
This  is  necessary  to  give  it  sufficient  length.  The  good  effect 
of  the  operation  is  to  be  ascribed  in  all  probability  in  far  greater 
degree  to  the  removal  of  the  deforming  force  than  to  the  extending 
action  of  the  flexor  muscles.  Except  in  the  very  mild  cases  of 
paraplegia,  and  as  an  aid  in  retaining  the  limbs  in  the  improved 
position  after  operative  treatment,  braces  are  of  little  value. 
The  trunk  is  not,  as  a  rule,  deformed  except  in  the  diplegic  cases 
in  which  the  mental  impairment  is  great.  Manipulation,  massage, 
and  posture  are  of  some  service  in  correcting  and  preventing  this 
distortion. 

Prognosis. — It  is  stated  by  Peterson^  that  the  patients  in  whom 
the  paralysis  is  paraplegic  or  diplegic  in  distribution  usually  die 
Ijcfore  the  twentieth  year,  and  that  but  few  of  those  in  whom 
it  is  hemiplegic  reach  the  age  of  forty.  This  prognosis  applies, 
it  may  be  assumed,  rather  to  the  extreme  cases  accompanied  by 
mental  impairment  than  to  the  milder  forms.  In  almost  all 
cases  the  patient,  even  if  idiotic,  is  finally  able  to  stand  and  to  walk. 
As  a  rule,  there  is  for  a  time  a  gradual  improvement  in  motor 
power  and  in  mental  control  as  well.  It  is  evident  that  in  a  class 
in  which  mental  enfeeblement  is  so  common  and  in  which  epilepsy 

1  Transactiona  American  Orthopedic  Association,  1900,  vol.  xiii. 


DISEASES  OF  THE  NEBVOUS  SYSTEM  633 

is  present  in  so  large  a  proportion  of  cases,  moral  and  mental 
training  is  of  great  importance. 

Orthopedic  treatment,  although  it  has  no  direct  action  upon 
the  lesion  in  the  brain,  certainly  has  an  indirect  effect  upon  the 
mental  as  well  as  upon  the  physical  condition  of  the  patient. 

When  deformity  has  been  corrected  and  when  contractions  have 
been  overcome,  functional  use  requires  less  mental  effort;  and 
motor  control  may  be  still  further  improved  by  drilling  the  patient 
constantly  in  simple  movements.  Such  exercises  improve  the 
motor  communications  and  the  ability  of  the  paralyzed  part  as 
well. 

Spastic  Spinal  Paralysis. 

Occasionally  one  encounters  cases  of  spastic  paraplegia  in 
which  there  is  no  cerebral  impairment.  In  such  cases  the  lesion 
appears  to  be  confined  to  the  spinal  cord  and  to  be  a  degeneration 
of  the  distal  portions  of  the  pyramidal  tracts  due  to  imperfect 
development.^  The  treatment  is  similar  to  the  ordinary  form  of 
spastic  paraplegia,  but  the  prognosis  is  far  more  encouraging. 

Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy,  as  the  term  implies,  is  a  progres- 
sive wasting  of  the  muscles,  with  corresponding  loss  of  power, 
terminating  finally  in  paralysis  and  deformity.  Its  cause  is 
apparently  some  developmental  defect. 

Under  this  title  are  included  two  varieties  of  disease: 

1.  The  myelopathic  form,  in  which  the  primary  disease  is 
apparently  of  the  spinal  cord. 

2.  The  myopathic  form,  in  which  the  disease  appears  to  be 
primarily  of  the  nerve  terminals  and  the  muscular  fibres. 

The  second  variety  is  usually  designated  as  muscular  dystrophy 
to  distinguish  it  from  the  spinal  form. 

Myelopathic  Paralysis  or  Atrophy.— The  myelopathic  form 
of  muscular  atrophy,  the  Aran-Duchenne  type,  usually  begins 
in  the  small  muscles  of  the  hands  and  spreads  from  the  periphery 
to  the  trunk.  Fibrillary  twitching  of  the  affected  antl  unatt"ected 
muscles  is  fairly  constant,  and  the  reaction  of  degeneration  may 
be  present.  The  disease  is  practically  limited  to  adults,  and 
from  the  ortliopedic  standpoint  it  is  of  little  interest.     In  another 

'  Spiller,  Pliiladelphia  Medical  Journal,  June  21,  1902. 


634 


ORTHOPEDIC  SURGERY 


form,  the  Charcot-^Iarie-Tooth  type,  usually  classed  with  the 
muscular  atrophies,  the  paralysis  may  begin  in  the  muscles  of  the 
legs,  causmg  deformity  of  the  equiuus  or  equinovarus  variety. 
The  lesion  of  the  cord  is  of  the  anterior  cornua,  and  resembles 
closely  that  of  the  stibacute  form  of  anterior  poliomyelitis. 


Fig.  405 


Fig.  406 


Progressive  muHcular  dystrophy, 
showing  the  enlargement  of  the  calves 
and  the  atrophy  of  the  shoulder  muscles. 


Progressive  muscular  dystrophy,  facio- 
scapulo-humeral  type.  Extreme  lordosis 
and  flexion  contractions  at  the  hips. 


Myopathic  Paralysis  or  Muscular  Dystrophy.— The  myopathic 
form  of  muscular  atrophy  may  be  [)receded  by  apparent  hyper- 
trophy (p.seudohypertrophic  muscular  paralysis),  it  may  be  pri- 
marily atrophic,  or  the  two  forms  may  be  combined. 


DISEASES  OF  THE  NERVOUS  SYSTEM  635 

It  differs  from  the  myelopathic  form  in  several  particulars. 
It  is  a  disease  of  childhood.  It  is  often  hereditary  and  its  dis- 
tribution is  different. 

The  affection  is  divided  according  to  the  distribution  into  two 
main  varieties: 

1.  The  facio-scapulo-humeral  type  (Landouzy-Dejerine),  in 
which  the  muscles  of  the  face  and  shoulder  girdle  are  })riinarily 
affecte;!  (Fig.  406). 

2.  The  juvenile  form  of  Erb,  in  which  the  muscles  of  the  back 
and  of  the  upper  arms  are  first  involved. 

The  etiology,  pathology,  and  clinical  course  of  the  atrophic 
do  not  differ  essentially  from  the  pseudohypertrophic  form. 

Pseudohypertrophic  Muscular  Paralysis.— Pseudohypertrophic 
paralysis  is  characterized  by  progressive  weakness  of  the  muscles 
oi  the  trunk  and  of  the  legs,  associated  with  apparent  liypertropliv 
of  the  calves  due  in  great  part  to  a  deposit  of  fat  in  the  wasting 
muscles  (Fig.  405). 

The  symptoms  are  caused  by  a  degenerative  atrophy  of  the 
nerve  terminals  and  of  the  muscular  fibres  and  an  increase  of 
the  connective  tissue  and  replacement  of  the  muscular  substance 
by  fat. 

Diagnosis. — The  interest  m  this  latter  affection  from  the  ortho- 
pedic standpoint  lies  in  the  diagnosis  in  the  early  stage  of  the 
affection.  At  this  time  the  patient  is  evidently  weak;  he  walks 
with  an  awkward,  shambling  gait,  and  climbing  stairs  is  especially 
difficult.  There  is  usually  an  increased  lordosis  and  a  pecidiar 
swaying  or  waddle,  a  disinclination  to  stoop,  and  an  evident 
difficulty  in  regaining  the  erect  posture,  and  there  may  be  dis- 
comfort or  pain  referred  to  the  lumbar  region.  If  the  disease 
is  advanced,  the  peculiar  hard,  resistant  enlargement  of  the  calves, 
combined,  it  may  be,  with  atrophy  of  the  muscular  groups  of  the 
upper  extremity,  and  weakness  of  the  muscles  of  the  back,  makes 
the  diagnosis  evident,  but  in  young  children  the  disease  may  be 
mistaken  for  Pott's  disease,  simple  weakness,  or  postural  deformity. 
Although  there  is  a  superficial  resemblance  to  the  general  symj)- 
toms  of  Pott's  disease,  yet  the  specific  signs  of  disease  of  the 
vertebne,  pain,  and  muscular  spasm  are  absent. 

Weakness,  a  result  of  malnutrition  or  disease,  is  general  in 
character  and  its  cause  is  usually  apparent;  it  is,  of  course,  not 
accompanied  by  local  hypertrophy.  Retarded  cerebral  develop- 
ment causes  general  weakness  as  far  as  inability  to  stand  is  con- 
cerneil,  but  the  cause  is  in  this  class  also  usually  apparent. 


636  ORTHOPEDIC  SURGERY 

Postural  deformities  in  childhood  always  have  a  cause,  and  as  one 
is  not  content  to  treat  a  deformity  without  ascertaining  its  cause, 
this  search  will  bring  to  light  the  peculiar  symptoms  of  the  disease. 

Treatment. — In  certain  instances  the  discomfort  referred  to 
the  back,  due  in  part  to  the  lordosis,  may  be  relieved  by  a  light 
spinal  support  Massage  and  muscle-training  will  enable  the 
patient  to  utilize  the  remaining  power  to  best  advantage. 

In  the  later  stages  of  the  disease  there  may  be  secondary  defor- 
mities, most  marked  in  the  feet,  which  may  be  fixed  in  the  equinus 
or  equinovarus  attitude.  This  deformity  may  be  corrected  by 
tenotomy  or  otherwise,  if  the  patient  has  not  already  become  so 
weak  that  walking  or  standing  is  impossible. 

Hereditary  Ataxia.     Friedreich's    Disease. 

Hereditary  ataxia  is  an  ataxic  paraplegia  caused  by  sclerosis  of 
the  posterior  and  lateral  columns  of  the  spinal  cord.  The  early 
symptoms  are  inco-ordination  and  weakness  of  the  legs;  later 
similar  symptoms  appear  in  the  upper  extremities,  and  speech  is 
affected.  In  well-marked  cases  there  is  usually  distortion  of  the 
feet  toward  equinus  or  equinovarus,  and  occasionally  a  posterior 
or  lateral  curvature  of  the  spine.  In  one  case  recently  under 
treatment  at  the  Hospital  for  Ruptured  and  Crippled,  the  recti- 
fication of  the  deformity  of  the  feet  was  at  least  of  temporary 
benefit. 

Neuritis. 

Localized  neuritis  after  contagious  disease  or  from  other  causes 
may  result  in  temporary  weakness  or  paralysis  of  the  dorsal 
flexors  of  the  foot,  cause  toe-drop,  and,  finally,  deformity.  In 
such  cases  the  foot  should  be  supported  by  a  brace  in  normal 
position.  This  not  only  prevents  deformity,  but  it  hastens  the 
cure  by  preventing  tension  upon  and  structural  lengthening  of 
the  weakened  muscles.  The  same  treatment  may  be  applied  for 
wrist-drop  from  metallic  poisoning.  The  hand  should  be  sup- 
ported by  a  suita})le  brace  in  the  attitude  of  dorsiflexion  until 
the  muscles  have  recovered  their  power.  Ol)stetrical  paralysis 
lias  been  considered  under  affections  of  the  shoulder. 

Hysterical  Joint  Affections  and  Deformities.    Functional 
Affections  of  the  Joints. 

So-called  hysterical  and  functional  afl:'ections  may  be  divided 
uito  two  groups: 


DISEASES  OF  THE  NERVOUS  SYSTEM  637 

1.  Those  in  which  there  is  no  actual  disease  or  weakness. 

2.  Those  in  which  the  symptoms  of  disease  or  injury,  or  of 
their  effects,  are  exaggerated  or  prolonged. 

The  first  class  of  cases  is  small,  the  second  is  large. 

Simulation,  whether  voluntary  or  involuntary,  of  organic  dis- 
ease can  deceive  only  those  who  are  not  familiar  with  the  char- 
acteristics of  the  disability  that  is  simulated.  Every  disease  has 
certain  well-defined  symptoms  which  can  no  more  be  imitated  by 
a  well  person  than  a  disabled  part  can  suddenly  take  on  the 
normal  appearance  and  function. 

"  Hysterical  Hip." 

The  hysterical  liip  is  supposed  to  simulate  actual  tuberculous 
disease. 

Diagnosis. — ^The  symptoms  of  actual  disease  of  this  joint  are 
pain,  limp,  limitation  of  motion  due  to  reflex  muscular  spasm, 
muscular  atropliy,  distortion,  and  in  the  later  stages  the  local 
signs  of  a  destructive  process;  for  example,  heat,  swelling,  abscess 
and  displacement  of  the  parts,  shortening  of  the  limb,  and  the 
like.  As  these  later  symptoms  could  not  be  simulated,  they  need 
not  be  considered. 

In  actual  disease  symptoms  and  effects  follow  one  another 
in  regular  sequence  and  correspond  closely  to  the  pathological 
conditions  that  cause  them.  Pam  is  not  a  pronounced  symptom; 
it  is  more  likely  to  be  concealed  than  exaggerated  and  it  is  usually 
referred  to  the  knee.  Local  sensitiveness  is  not  marked,  and  it 
is  often  absent.  Distortion  of  the  limb  when  it  occurs  in  the 
early  stage,  before  the  destructive  changes  are  advanced,  is  caused 
by  involuntary  muscular  contraction,  and  whenever  this  dis- 
tortion is  great  the  reflex  muscular  spasm,  which  involves  every 
muscle  about  the  joint,  is  also  great;  so  that  the  range  of  m'^*ion 
in  the  joint  is  small,  and  it  may  be  absolutely  restricted.  With 
the  distortion  there  is  always  a  corresponding  atrophy  of  the 
muscles  of  the  limb.  If  pain  is  present  it  is  usually  worse  at  night 
than  during  the  day. 

The  hysterical  simulation  of  hip  disease  is  characterized  by  an 
exaggeration  of  the  symptoms  and  by  absence  of  the  physical 
signs  of  disease.  There  is  usually  an  exaggerated  limp,  great 
distortion,  marked  local  sensitiveness  and  pain,  but  absence  of 
muscular  spasm,  atrophy,  or  other  signs  of  disease. 

The  age  of  the  patient,  the  history  of  the  supposed  disease,  and 


638  ORTHOPEDIC  SURGERY 

the  other  evidences  of  hysteria  that  are  usually  present  will  con- 
firm the  diagnosis. 

The  same  principle  applies,  of  course,  to  the  differential  diag- 
nosis of  simulated  disease  at  other  jomts.  The  knee  and  the 
hip-joint  are  those  that  are  most  often  involved. 

Hysterical   Deformities. 

"Hysterical  Club-foot." — Local  deformity  distinct  from  simu- 
latei-l  joint  disease  is  sometimes  seen.  Several  cases  of  this  char- 
acter in  which  the  foot  was  distorted  have  been  under  treatment 
at  the  Hospital  for  Ruptured  and  Crippled  recently.  The  differ- 
ential diagnosis  is  simple. 

Talipes  is  either  congenital  or  acquired.  Congenital  talipes 
and  all  the  acquired  varieties,  other  than  those  of  paralytic  origin, 
mav  be  at  once  excluded  from  consideration.  Paralytic  talipes 
in  the  great  majority  of  cases  begins  in  early  childhood,  when  it  is 
either  caused  by  anterior  poliomyelitis  or  by  cerebral  hemiplegia 
or  paraplegia.  "^Mien  these  are  excluded  the  remaining  causes 
of  deformity  are  very  limited.  Every  variety  of  nervous  disease 
has  well-defined  symptoms.  If  actual  paralysis  is  present  the 
muscles  atrophy  and  the  electrical  reactions  are  changed.  In 
hysterical  contractions  the  muscles  do  not  atrophy,  and  the  elec- 
trical reactions  are  unchanged. 

"Hysterical  Scoliosis." — A  case  was  at  one  time  under  observa- 
tion at  the  Hospital  for  Ruptured  and  Crippled  in  which  distortion 
of  the  trunk  persisted  for  more  than  a  year,  and  luitil  a  suit  for 
damages  was  finally  decided.  In  this  case  there  was  a  most 
exaggerated  lateral  twist  of  the  spine,  so  that  the  shoulder  ap- 
proacherl  the  pelvis.  The'  deformity,  however,  was  not  fixed, 
but  it  could  be  completely  reduced  when  the  patient  was  in  the 
recumbent  posture.  There  was  no  paralysis,  no  persistent  spasm, 
no  evidence  of  disease  or  injury.  The  deformity  was  of  a  nature 
that  could  not  be  explained  by  any  conceivable  lesion,  and  other 
signs  of  hysteria  were  present. 

Treatment. — ^The  principles  of  the  treatment  of  pronounced 
hysteria,  of  which  simulated  joint  disease  or  deformity  are  but 
unusual  manifestations,  are  considered  at  length  in  medical  and 
neurological  works,  and  the  subject  does  not  call  for  special 
mention  here.  It  is  evident,  of  course,  that  an  unequivocal 
diagnosis  must  Vje  the  first  and  essential  step  toward  cure.  In  this 
class  of  cases  apparatus  is  not  often  indicated  unless  the  deformity 


DISEASES  OF  THE  NERVOUS  SYSTEM  639 

has  persisted  for  so  long  a  time  that  the  disused  muscles  have  be- 
come incapable  of  performing  their  proper  functions. 

Functional  Affections  of  the  Joints. 

"Neurotic  Joints." — In  this  class,  although  there  is  no  abso- 
lute distinction  between  it  and  the  precedmg  variety,  there  is 
usually  a  physical  basis  for  the  symptoms,  however  much  they 
may  be  exaggerated. 

The  patients  are  not  usually  hysterical;  in  fact,  hysteria  in 
the  ordinarily  accepted  sense  is  uncommon,  and  although  the 
larger  proportion  of  patients  are  women,  yet  men  and  children 
are  by  no  means  exempt  from  the  so-called  functional  affec- 
tions. 

It  must  be  borne  in  mind,  also,  that  many  of  these  cases  are 
classed  as  neurotic  simply  because  the  cause  of  the  symptoms  is 
not  apparent.  It  is  only  within  a  few  years  that  the  slighter 
degrees  of  weak  foot  and  its  effects  have  been  recognized,  and  it 
is  probable  that  such  cases,  together  with  anterior  meta tarsalgia, 
the  painful  fascia  of  the  contracted  foot,  achillodynia,  and  the 
like  might  be  considered  as  neurotic  by  one  unfamiliar  with  their 
symptoms.  It  may  be  inferred  that  as  diagnosis  becomes  more 
accurate  the  more  restricted  will  become  the  class  of  cases  of 
purely  imaginary  disability,  in  so  far  at  least  as  the  locomotive 
apparatus  is  concerned. 

A  "neurotic  joint"  is  often  caused  by  injury.  A  sprain  of 
the  ankle,  for  example,  may  have  been  treated  by  prolonged 
immobilization,  either  because  the  patient  had  originally  impressed 
the  physician  with  the  severity  of  the  symptoms  or  because  of 
persistent  discomfort.  When  the  dressing  is  removed  there  may 
be  congestion  due  to  impaired  circulation,  Aveakness  and  atrophy 
of  the  muscles  due  simply  to  disuse,  and  a  certain  degree  of 
infiltration  and  stiffness  caused  by  the  original  injury.  In  cases 
of  this  character  tlie  disability  may  be  prolonged  because  the 
patient  or  tlie  physician  mistakes  the  effects  of  disuse  for  the  symp- 
toms of  serious  injury  or  disease.  When  the  diagnosis  has  been 
made  treatment  should  be  directed  to  increasing  the  activity 
of  the  circulation  and  thus  the  nutrition  of  the  part,  by  coimter- 
irritation,  by  massage,  by  passive  movements,  by  voluntary 
exercises  and  tlie  like,  but  cure  can  only  be  completed  by  restoring 
functional  use.  If,  therefore,  the  disability  is  of  long  standing 
a  brace  may  be  required  for  a  time  to  protect  the  part  from  injury, 


640  ORTHOPEDIC  SUBGEBY 

and  to  increase  the  patient's  confidence.  In  milder  cases  it  is 
possible  that  \sathout  support  or  treatment,  other  than  an  assurance 
of  the  absence  of  serious  weakness,  cure  may  be  accomplished, 
but  this  is  certainly  unusual. 

What  has  been  said  of  exaggerated  disability  at  the  ankle  fol- 
lowing traumatism  applies  to  the  treatment  of  similar  affections 
elsewhere.  The  knee-joint  is  very  often  the  seat  of  so-called 
neurosis.  Injury  at  this  point  in  nervous  children  is  sometimes  fol- 
lowed by  a  persistent  flexion  contraction  that  may  continue  for 
weeks  after  all  signs  of  the  injury  have  disappeared.  When  the 
attempt  is  made  to  straighten  the  knee  the  patient  screams  with 
pain  and  the  muscular  resistance  is  very  great.  In  such  cases 
the  immediate  rectification  of  deformity  and  the  application  of  a 
plaster  bandage  to  hold  the  limb  in  the  corrected  position  is 
indicated.  It  must  be  borne  in  mind  that  the  persistent  assump- 
tion of  a  deformed  position  for  weeks  or  months  must  be  followed 
by  certain  structural  changes  in  the  contracted  muscles  and  weak- 
ness in  the  opposing  groups.  Thus  some  assistance  may  be 
required  in  the  treatment  even  of  the  purely  hysterical  deformities 
because  of  this  weakness. 

In  all  forms  of  traumatic  neurosis,  so-called,  the  possibility  of 
a  physical  basis  for  the  symptoms  should  be  considered,  the 
location  of  the  pain  or  discomfort,  and  its  connection  with  cer- 
tain movements  or  attitudes  should  be  investigated.  If  such 
discomfort  is  induced  or  is  aggravated  by  a  certain  motion  or 
attitude  it  is  reasonable  to  infer  that  this  has  a  well-defined 
cause,  especially  as  the  pain  of  a  neurotic  affection  is  not  often  of 
this  definite  character.  In  such  cases  limitation  of  the  move- 
ments for  a  time  to  the  painless  range  of  motion  by  some  form  of 
support  may  be  indicated. 

Thus  far  injury  has  been  considered  as  the  starting  point  of 
the  symptoms,  but  in  many  cases  there  is  no  history  of  injury. 
In  this  class  the  symptoms  may  have  been  induced  by  rheu- 
matism or  gout  or  rheumatoid  arthritis,  or  by  neuritis,  and  such 
possible  causes  should  be  investigated  and  excluded  before  the 
diagnosis  of  simple  neurosis  is  made.  In  neurasthenic  patients 
or  those  who  are  anaemic,  or  overworked,  the  pain  and  discomfort 
is  often  localized  in  the  spine.  The  "neurotic  spine"  has  been 
considered  elsewliere.  In  tlie  treatment  of  all  cases  of  this  group 
the  general  condition  of  the  patient  should  receive  consideration, 
and  in  connection  with  the  local  treatment  a  change  of  occupa- 
tion and  of  scene  is  often  of  advantage. 


DISEASES  OF  THE  NERVOUS  SYSTEM  641 

It  is  hardly  necessary  to  insist  again  tliat  an  accurate  diagnosis 
is  the  first  essential  of  successful  treatment.  If  this  is  impossible 
at  least  one  may  by  exclusion  of  those  injuries  and  disabilities 
and  diseases  which  are  evidently  not  present  arrive  at  a  general 
conclusion  as  to  the  character  of  the  ailment  and  shape  his  treat- 
ment accordingly. 


41 


CHAPTER    XIX. 

CONGENITAL   AND   ACQUIRED  TORTICOLLIS. 

Synonym.  — Wryneck. 

Torticollis  is,  as  the  name  implies^  a  twisted  neck,  a  distortion 
caused  in  most  instances  by  active  contraction  or  by  shortening 
of  one  or  more  of  the  lateral  muscles  that  control  the  head. 

Similar  distortion  may  be  due  to  disease  of  the  spine,  so-called 
false  torticollis,  but  this  should  be  classed  as  a  symptom  of  the 
underlying  disease,  not  as  simple  torticollis,  of  which  the  distor- 
tion itself  is  the  important  disability  that  demands  treatment. 

Torticollis  may  be  divided  primarily  into  two  classes:  The 
congenital  and  the  acquired. 

Congenital  torticollis  is  a  painless  shortening  of  the  tissues  on 
one  side  of  the  neck  of  intrauterine  origin. 

I  -  Acquired  torticollis  is,  in  most  instances,  accompanied  in  its 
early  stages  by  local  pain  and  sensitiveness,  and  by  active  con- 
traction of  the  affected  muscles.  After  a  time  these  acute 
symptoms  disappear,  leaving  simply  the  deformity.  Thus,  from 
the  therapeutic  standpoint,  torticollis  may  be  classified  as  acute 
and  chronic,  the  latter  class  including  the  congenital  form. 

The  sternomastoid  is  the  muscle  that  is  usually  involved  pri- 
marily, both  in  the  congenital  and  accjuired  forms;  thus,  in  typical 
torticollis  the  head  is  drawn  somewhat  forward  and  is  inclined 
toward  the  contracted  muscle,  while  the  neck  is  pushed,  as  it 
were,  away  from  the  contraction  (Fig.  407);  the  chin  is  slightly 
elevated,  and  turned  toward  the  opposite  shoulder — an  attitude 
explained  by  the  normal  action  of  the  affected  muscle.  Irregular 
distortions  of  the  head,  as  posterior  or  anterior  torticollis  due  to 
contraction  of  muscles  other  tlian  the  sternomastoid,  are,  however, 
not  infrequent.  These  will  be  mentioned  in  the  consideration  of 
the  forms  of  acquired  torticollis. 

Statistics. —Torticollis  is  comparatively  an  uncommon  defor- 
mity. In  a  period  of  twenty-seven  years  507  cases  were  treated 
at  the  Hospital  for  Ruptured  and  Crippled,  as  contrasterl  with 
upward  of  .5000  cases  of  congenital  and  acquired  talipes. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  643 

Acquired  torticollis  is  by  far  the  more  common  variety,  as  is 
shown  by  the  fact  that  of  the  507  cases  but  87  were  supposed  to 
be  of  congenital  origin. 

It  is  often  stated  that  torticollis  is  more  common  in  males  than 
in  females,  and  that  the  right  side  is  more  often  a  fleeted,  yet  46 
of  the  87  congenital  cases  were  in  females  and  tlie  contraction 
was  of  the  left  side  in  38  of  the  58  cases  in  which  the  affected 
side  was  specified.  Of  the  entire  number  of  cases  available  for 
comparison  246  were  in  females  and  198  in  males;  in  236  instances 
the  contraction  was  on  the  left  and  in  196  on  the  right  side  of  the 
neck.  From  these  statistics  it  would  appear  that  tlie  deformity 
is  somewhat  more  common  in  females  than  in  males,  and  that 
the  left  side  is  more  often  affected  than  the  right. 

Congenital   Torticollis. 

In  most  instances  the  deformity  of  congenital  torticollis  is 
slight  at  birth,  and  it  may  not  attract  attention  until  the  child 
sits  or  walks.  Thus  it  is  often  difficult  to  distinguish  the  con- 
genital form  from  the  deformity  that  may  have  been  acquired 
in  infancy,  especially  as  the  patient  may  not  be  brought  for  treat- 
ment until  the  distortion  has  persisted  for  many  years. 

In  early  infancy  slight  torticollis  may  be  demonstrated  by 
fixing  the  shoulder  on  the  affected  side  and  drawing  the  head 
forcibly  in  the  opposite  direction,  when  the  shortened  muscle 
becomes  prominent  beneath  the  skin,  evidently  restricting  the 
range  of  motion.  In  most  instances  the  sternal  division  of  the 
muscle  appears  to  be  more  shortened  than  the  clavicular  portion. 

In  exceptional  cases  the  deformity  even  in  infancy  may  be 
extreme,  and  it  may  be  accompanied  by  well-marked  asymmetry 
of  the  face  and  even  by  distortion  of  the  skull.  In  this  class 
the  shortening  may  involve  all  the  lateral  tissues,  both  anterior 
and  posterior.  If  asymmetry  is  present  at  birth  it  increases 
somewhat  with  growth.  Even  in  the  acquired  form  it  often 
appears  soon  after  the  onset  of  the  deformity,  becoming  more 
marked  with  its  continuance.  Its  cause  is  the  constrained  attitude, 
the  restriction  of  normal  use,  and  consequently  of  the  blood  supply, 
combined  with  the  tension  upon  the  tissues  of  the  face,  as  is 
evidenced  by  the  fact  that  it  becomes  less  noticeable  after  the 
deformity  has  been  corrected. 

In  the  well-marked  cases  of  long  standing:,  whether  congenital 
or  acquired,  the  face  is  shorter  and  flatter,  tlie  nose  and  the  corner 


644 


ORTHOPEDIC  SURGERY 


of  the  mouth  and  the  eyelids  even  on  the  affected  side  are  drawn 
downward,  and  the  skull  shows  evidence  of  atrophy  and  deformity. 

Secondary  distortions  also  appear  in  the  trunk  in  chronic  cases. 
These  are  rotation  of  the  spine  to  compensate  for  the  lateral  dis- 
tortion of  the  heatl  and  an  increase  in  the  dorsal  kyphosis,  "round 
shoulders."  Among  the  minor  secondary  deformities  upward 
bowing  of  the  clavicle  caused  by  the  tension  of  the  contracted 
muscle  may  be  mentioned  (Fig.  407). 

In  the  early  stage  of  torticollis  the  head  is  tilted  toward  the 
contracted  tissues,  but  when  the  deformity  is  of  longer  standing 


Ftc.   407 


Left  torticolli.s,  apiiarciitly  of  congenital  oiigin,  showing  the  secondary  distortions  of 

head  and  face. 


the  head  following  the  compensatory  convexity  of  the  cervical 
s[Miie  is  displaced  toward  the  opposite  shoulder  (Fig.  40S).  Tliis 
relieves  it  from  the  direct  iuHuence  of  the  contracted  tissues,  con- 
sefpiently  the  lateral  distortion  is  less  marked. 

The  ronij)cnsatory  (k'formities  that  have  been  indicated  are 
slight  ill  infancy,  but  tliey  develop  in  later  childhood,  for  in  many 
instances  the  shortene  I  muscle  ceases  to  grow;  thus,  an  original 
shortening  of  half  an  inch,  as  compared  to  its  fellow,  may  be 
increased  to  two  or  nujrc  inches  in   later  years.     This  fact  em- 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS 


IS   lii;i\'   h( 


G45 

'  ])()ssil)lt' 


pliasizes  the  iraporttuice  of  treutiueiit  as  soon  <i 
after  distortion  is  discovered. 

As  has  been  staterl,  the  important  contraction  is  usually  of  the 
sternomastoid  muscle,  but  if  the  deformity  is  uncorrected  all  the 
lateral  tissues  become  shortened. 

Typical  wryneck  caused  by  shortening  of  the  sternomastoid 
muscle  is  by  far  the  most  common  form  of  congenital  torticollis, 
but  occasionally  cases  are  seen  in  which  the  head  is  but  slightly 
incUned  to  one  side  and  in  which  the  shortening  appears  to  involve 
the  lateral   tissues   in   general   rather  than    a    particular   muscle. 


Fig.    408 


Right  torticollis,  showing  the  displacement  of  the  hetul  towanl  the  opposite  side. 

In  rare  instances,  although  the  deformity  resembles  that  of  typical 
torticollis,  the  greatest  shortening  will  be  found  to  be  of  the 
posterior  muscles  on  one  side,  particularly  of  the  trapezius  and 
the  levator  anguli  scapula\  Thus  the  scapular  may  be  elevated 
and  tilted  forward.  This  form  of  torticollis  appears  to  be  one 
variety  of  congenital  elevation  of  the  sca{)ula.  (See  page  231.) 
Torticollis  due  to  defective  development  of  tiie  upper  extremity  of  the 
spine  is  a  rare  deformity  that  does  not  require  special  description. 

Etiology. — It  may  be  assumed,  disregarding  the  possil)le  influ- 
ence of  hereditary  pre:lis[)()sition,  that  congenital  torticollis  is,  in 


646  ORTHOPEDIC  SUBGEBY 

most  instances,  caused  by  a  constrained  or  fixed  position  in  tlie 
uterus  for  a  longer  or  shorter  time  before  birth.  It  is,  in  fact, 
a  simple  distortion,  and  tliat  it  has,  m  the  majority  of  cases,  no 
deeper  significance  is  proved  by  the  fact  that  it  may  be  easily 
and  completely  cured  by  simple  division  or  elongation  of  the 
contracted  tissues. 

It  would  seem  that  a  deformity  to  be  properly  congenital  must 
be  present  at  birth,  yet  the  theory,  first  advanced  by  Stromeyer, 
that  congenital  torticollis  is  usually  the  result  of  injury  at  birth 
has  been  so  generally  accepted  that  it  merits  further  consideration. 

Haematoma  of  the  Sternomastoid  Muscle. — Hematoma  is  con- 
sidered to  be,  and  undoubtedly  is,  evidence  of  injury.  During 
difficult  delivery,  fibres  of  the  muscle  are  ruptured,  usually  in 
the  upper  or  middle  tliird  of  the  anterior  border,  hemorrhage 
follows,  which  in  turn  is  surrounded  by  an  encapsulating  area  of 
inflammatory  material.  This  forms  a  firm,  cylindrical  tumor  in 
the  substance  of  the  muscle,  which  becomes  noticeable  about  two 
weeks  after  birth,  or  at  least  this  is  the  time  when  it  is  usually 
discovered  by  the  mother.  As  a  rule,  the  tumor  is  not  sensitive 
to  pressure;  it  may  or  may  not  be  accompanied  by  restriction  of 
motion  m  the  direction  causing  tension  on  the  muscle.  The 
tumor  remains  for  from  three  to  six  months,  when  it  usually 
disappears,  leavmg  no  trace  of  its  presence. 

The  theory  of  Stromeyer,  which  until  recently  was  generally 
accepted,  is  that  congenital  torticollis  is  usually  caused  by  rupture 
of  the  muscle  and  by  myositis  about  the  haematoma.  This  inflam- 
mation may  involve  and  ultimately  destroy  a  large  part  of  the 
substance  of  the  muscle,  replacing  it  with  fibrous  tissue,  which, 
contracting,  causes  deformity. 

This  theory  is  extremely  improbable  for  the  following  reasons: 

1.  Rupture  of  muscle  elsewhere  is  practically  never  followed 
by  myositis  and  contraction. 

2.  It  has  been  demonstrated  by  Heller^  that  it  is  impossible 
to  cause  myositis  and  contraction  by  any  form  of  injury  to  the 
muscles  of  animals  unless  it  be  combined  with  actual  infection 
with  pyogenic  germs. 

3.  Most  of  the  cases  of  congenital  torticollis  seen  soon  after 
birth  present  no  evidence  of  haematoma  or  injury,  viz.:  In  7  of  55 
cases  of  supposed  congenital  torticollis,  investigated  by  the  writer, 
there  was  a  history  of  injury  at  birth.  In  48  cases  no  mention 
was  made  of  injury.     In  the  7  cases  referred  to   the  deformity  was 

•  ]li;ll.;r,   Dcul.sr:li.   Zeits.  f.  Chir..  Hd.  xlix..  H.  2  and  :'.,  S.  234. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  647 

accompanied  by  hsematoma  or  tliere  was  a  history  of  a  swelling, 
apparently  of  this  nature;  but  in  2  of  these  the  hsematoma  was 
coincident  with  intrauterine  shortening  of  the  muscle. 

4.  Cases  of  hematoma  of  the  sternomastoid  muscle  are  not,  as 
a  rule,  followed  by  torticollis.  Seven  consecutive  cases  of  hsema- 
toma  were  examined  by  the  writer  with  special  reference  to  this 
point.  In  all  the  evidence  of  violence  in  delivery  was  clear. 
Two  were  delivered  by  forceps,  3  were  breech  presentations, 
and  in  2  version  was  performed.  In  1  case  an  arm  was  broken 
and  in  another  paralysis  resulted  from  injury  to  the  brachial 
plexus.  Six  of  the  children  lived  until  the  swelling  had  nearly 
or  entirely  disappeared,  and  in  none  did  torticollis  accompany 
or  follow  the  haematoma. 

5.  In  certain  cases  a  congenitally  shortened  muscle  may  be 
ruptured  at  delivery;  thus  the  haematoma  is  simply  a  complica- 
tion of  torticollis,  not  its  cause.  Bruns^  has  reported  such  a 
case,  and  two  others  have  been  observed  by  the  writer,  in  one  of 
which  club-foot  was  present  also. 

6.  Hard  tumors  of  the  sternomastoid  muscle  are  not  always 
the  result  of  injury;  myositis  may  be  of  syphilitic  origin  appar- 
ently occurring  in  intrauterine  life.  In  other  instances  tumors 
of  fibrous  or  sarcomatous  nature  have  been  removed  from  the 
substance  of  the  muscle.  Sixteen  cases  in  which  cartilaginous 
nodules,  apparently  of  congenital  origin,  were  found  in  the  muscle 
have  been  reported.^ 

One  may  conclude  then  that  congenital  torticollis  in  the  majority 
of  cases  is  of  intrauterine  origin.  If  it  follows  injury  at  birth 
it  is  probably  an  indirect  result  of  local  pain,  discomfort,  antl 
irritation  of  the  nerves  or  of  an  actual  infectious  inflammation  of 
the  injured  part  rather  than  an  effect  of  the  absorption  of  effused 
blood. 

Pathology. — -In  the  ordinary  type  of  congenital  torticollis,  as 
demonstrated  at  operations  on  children,  the  substance  of  the 
affected  muscle  or  muscles  is  simply  lessened  m  amount,  and  there 
is  a  disproportionate  area  of  tendinous  substance  as  compared 
to  the  contractile  tissue.  In  other  instances  the  muscle  may  be 
almost  entirely  replaced  by  fibrous  tissue  or  it  may  be  traversed 
by  fibrous  bands,  or  patches  of  scar-like  tissue  may  be  distributed 
throughout  its  substance.  These  degenerative  changes,  consid- 
ered to  be  evidences  of  pre-existing  myositis,  are  probably  more 
common  among  the  acquired  than  the  congenital  form,  and,  as  a 

1  Zent.  f.  Chir.,  1891,  No.  26.  -  Leugemann,  Beitr.  z.  klin.  Cliir.,  Bd.  xxx..  11.  1. 


648  OE THOPEDW  SURGERY 

rule,  they  are  found  only  in  cases  of  long  standing.  Secondarily 
all  the  lateral  tissues  of  the  neck  are  shortened  to  correspond  to 
the  habitual  attitude,  and  the  compensatory  curvatures  of  the  spine 
in  time  become  fixed,  so  that  torticollis  may  be  classed  as  one  of 
the  causes  of  scoliosis. 

Acquired  Torticollis. 

Acquired  torticollis  is  an  affection  of  early  life,  at  least  80  per 
cent,  of  the  cases  beginning  in  the  first  ten  years  of  life. 

As  has  been  state:!,  congenital  torticollis  is  usually  a  painless 
shortening  of  the  muscles,  while  acquired  torticollis  is,  as  a  rule, 
a  painful  affection  secondary  to  injury  or  disease  of  some  of  the 
structures  of  the  neck,  which  causes  irritation  of  the  peripheral 
nerves  and  active  contraction  of  the  neighboring  muscles.  Thus, 
as  a  rule,  the  number  of  muscles  involved  in  the  deformity  is 
greater  than  in  the  congenital  form;  for  example,  in  the  ordinary 
form  of  acquired  wryneck  both  the  trapezius  and  the  sterno- 
mastoid  are  contracted;  and  irregular  forms  of  distortion  caused 
by  spasm  of  other  muscular  groups  are  not  uncommon. 

Varieties. — The  varieties  of  acquired  torticollis  may  be  clas- 
sified conveniently  as  follows: 

1.  The  simple  or  mechanical  form  due  to  scar  contraction  fol- 
lowing destruction  of  the  skin  or  deeper  tissues,  as  from  burns 
or  disease. 

2.  Acute  torticollis  caused  by  direct  irritation  of  the  muscle, 
by  injury,  by  inflammatory  affections  of  the  surrounding  parts, 
combine!  1  in  most  instances  with  irritation  of  the  peripheral 
nerves,  which  causes  reflex  contraction  of  certain  muscles  or 
muscular  groups. 

3.  Spasmodic  Torticollis. — -A  form  of  convulsive  spasm,  "a  dis- 
order of  the  cortical  centres  for  rotation  of  the  head."     (Walton.) 

4.  Irregular  Forms  of  Torticollis. — Paralytic,  ocular,  psychical, 
and  the  like. 

The  first  class,  tliat  due  to  scar  contraction,  needs  only  to  be 
mentioned. 

Etiology  of  Acute  Torticollis. — ^The  second  class  is  the  most 
important  form  of  torticollis,  both  as  to  frequency  and  as  to  its 
effect  in  causing  permanent  distortion.  Of  this  group,  one  of  the 
most  common  and  at  the  same  time  the  least  important  form  is 
the  simple  stiff  neck,  supposed  to  be  due  to  cold  or  to  muscular 
rheuinatisin.     Its  onset  is,  in   childhood,  sometimes  accompanied 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  649 

by  slight  fever  and  malaise;  the  affected  muscle  is  somewhat 
sensitive  to  pressure  and  motion  or  tension  causes  discomfort. 
The  distortion,  in  great  part  voluntary  and  accommorlative,  is  of 
short  duration  as  a  rule.  Strains  and  direct  injury  of  the  muscles 
of  the  neck  may  cause  deformity,  which  usually  disappears  when 
the  local  sensitiveness  has  subsiderl.  Traumatic  ha?matomata, 
similar  to  those  caused  by  injury  at  birth,  are  sometimes  oi)served 
in  older  subjects.  These  usually  disappear  after  a  time,  leaving 
no  trace  of  their  presence. 

Another  form  of  torticollis  is  secondary  to  cellulitis  and  to  in- 
filtration following  the  breaking  down  of  tuberculous  cervical 
glands.  This  may  become  a  permanent  distortion  if  the  defor- 
mity is  allowe  1  to  persist  or  if  the  tissues  of  the  neck  are  injured 
by  the  suppurative  process. 

By  far  the  most  important  variety  of  this  class  is  the  acute 
spastic  torticollis  due  to  active  tonic  contraction  of  one  or  more 
of  the  muscles  of  the  neck.  The  exciting  cause  of  the  spasm 
appears  to  be  irritation  of  the  peripheral  nerves  in  the  naso- 
pharynx or  in  its  neighborhood,  and  the  muscles  most  often 
affected  are  those  supplied  in  part  by  the  spinal  accessory  nerve. 
Thus,  torticollis  of  this  form  may  follow  tonsillitis,  pharyn- 
gitis, measles,  diphtheria  and  the  like.  It  may  be  preceded  by 
"toothache"  or  "earache,"  or  it  may  be  an  accompaniment  of 
what  appears  to  be  the  ordinary  form  of  stiff  neck  or  of  enlarged 
or  suppurating  cervical  glanfls.  In  this  form  the  torticollis  is 
caused  directly  by  tonic  contraction  of  the  muscles.  Reflex  spasm 
of  this  character  is,  however,  often  associated  with  distortion, 
due  primarily  to  injury  of  the  neck  or  to  some  local  inflammatory 
process,  so  that  a  sharp  distinction  between  the  divisions  of  this 
second  class  is  impossible.  IVIany  of  the  patients  are  known  to  be 
of  a  nervous  temperament,  and  overstudy,  anxiety,  sudden  shock, 
and  the  like  are  considered  to  be  predisposing  causes. 

This  variety  of  acquired  torticollis  completely  overshadows  in 
importance  all  other  forms,  as  is  indicated  by  the  statistics  of  212 
cases  treatetl  at  the  Hospital  for  Ruptured  and  Crij)pleii,  in  which 
the  cause  seemed  to  be  apparent.  Of  the  212  cases  ISl  may  be 
fairly  assigned  to  this  class. 

The  apparent  exciting  causes  of  cases  of  accjuired  torticollis 
treated  at  the  Hospital  for  Ruptured  and  Crippled  are  shown  in 
the  following  table: 


650  ORTHOPEDIC  SURGERY 

Enlarged  cer\-ical  glands   ...  14         "Cold  in  the  neck" 5 

Suppurating     "           '          ...  41         Rheumatism 18 

Scarlet  fever 14         Vaccinia 1 

Diphtheria 7         Fever 6 

Jlumps 6         Malaria 5 

Measles 2  Injury  by  the  neck       ....  35 

Sore-throat 8         Rhachitis 3 

Suppurative  otitis 3         Syphilis 1 

Toothache 6  Cicatricial  contraction  ....  3 

Cellulitis  of  the  neck    ....  2                                                                        

Furuncle     "           "        ....  1                 Total 181 

Torticollis  associated  with  chorea 4 

"      epilepsy 1 

"  "  "      cortical  uritation 5 

"  "  "      hysteria 1 

"  "  "      meningitis 1 

"  "  "      hemiplegia 3 

Spasmodic  torticollis 8 

"Functional  torticollis" 8 

Total 31 

Symptoms  of  Acute  Torticollis. — As  a  rule,  the  distortion  of 
the  neck,  slight  at  first,  is  more  noticeable  at  night  than  in  the 
morning;  it  then  gradually  increases  until  the  deformity  becomes 
fixed.  In  other  instances  the  onset  is  sudden,  sometimes  accom- 
panied by  fever. 

As  has  been  stated,  in  most  instances  several  muscles  are  more 
or  less  involved  in  the  contraction,  particularly  the  sternomastoid 
and  the  trapezius,  and  in  such  cases  the  deformity  is  more  marked 
and  persistent  than  when  the  sternomastoid  is  alone  affected. 
Less  often  the  contraction  is  of  the  posterior  group,  '^  posterior 
torticollis"  (Fig.  411),  when  the  head  is  tilted  backward  and  the 
chin  is  turned  more  toward  the  opposite  side  than  in  the  typical 
lateral  form.  In  other  cases  the  contraction  appears  to  affect  the 
small  muscles  that  control  the  joints  at  the  upper  extremity  of  the 
spine,  when  the  head  may  be  tilted  forward  with  but  slight  lateral 
inclination,  resembling  closely,  except  in  the  liistory,  the  symp- 
tomatic wryneck  of  Pott's  disease.  In  rare  instances  the  muscles 
on  both  sides  of  the  neck  may  be  contracted  simultaneously 
(Fig.  409).  The  contracted  muscles  are  usually  sensitive  to 
manipulation  and  attempterl  rectification  of  the  deformity  causes 
extreme  pain  and  is  resisted  by  the  patient.  The  child  is,  as  a 
rule,  nervous  anfl  irritable;  it  often  complains  of  neuralgic  pain 
about  the  contracted  parts,  which  is  increased  by  sudden  or, 
unguarded  movements  or  strain;  thus  "getting  the  patient  to  bed' 
is  often  a  tedious  proceeding,  because  of  the  difficulty  of  supporting 
the  head  comfortably  with  the  pillows. 

In  many  instances  the  affection  is  of  short  duration;  in  others 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS 


651 


particularly  those  in  which  tlie  reflex  spasni  is  aggravated  by 
local  inflammatory  processes,  there  appears  to  be  but  little  ten- 
dency toward  recovery.  In  such  cases,  after  several  weeks  or 
months,  the  local  pain  and  sensitiveness  may  subside,  together 
with  the  active  spasm,  but  the  deformity,  caused  by  adaptive 
shortening  of  the  muscles  and  fascia,  aggravated  in  some  instances 
by  actual  myositis,  persists.  The  muscles  atrophy  and  degen- 
erate and  present  at  a  later  stage  the  same  pathological  appear- 
ances that  are  found  in  the  congenital  form. 

Diagnosis. — ^Torticollis  is  most  often   confounded  witii  Poifs 
disease.     Tliis  would  seem  to  be  hardly  possible  in  cases  of  the 


Fig.   409 


Fig.   410 


Bilateral  contraction  of  the  sternomastoid 
and  trapezii  muscles.     (See  Fig.  410.) 


Bilateral  torticollis  after  treatment. 
(See  Fig.  409.) 


simple  painless  contraction  of  chronic  torticollis.  In  the  acute 
form,  however,  there  may  be  more  difficulty  in  distinguishing 
between  the  two.  The  mam  points  have  been  mentioned  already 
in  connection  with  Pott's  disease.  In  acute  torticollis  the  afl'ec- 
tion  is  of  sudden  onset,  not  preceded  by  the  stiffness  and  neuralgic 
pain  that  characterize  tuberculous  disease.  The  deformity  of 
torticollis  is  almost  always  of  the  regular  type — tliat  is,  the  heatl 
is  tilted  toward  the  contracted  muscles  while  the  chin  is  rotated 
in  the  opposite  direction.     The  spasm  and  contraction  of  the 


652 


ORTHOPEDIC  SURGERY 


atfected  muscles  are  apparent,  and  direct  tension  upon  them  is 
painful.  If,  however,  the  tension  is  relaxed  by  inclining  the 
head  toward  the  contraction,  movement  of  the  head  in  other  direc- 
tions will  be  found  to  be  practically  unrestricted. 

In  Pott's  disease  the  spasm  of  muscles  is  general,  the  deformity 
is  not  of  a  regular  type,  since  the  chin  often  points  to  the  side 
toward  which  the  heail  is  inclined.     Steadv  tension  with  the  aim 


Posterior  torticollis.      Duration  one  week. 

of  reducing  tlie  deformity  is  not,  as  a  rule,  painful;  in  fact,  it  is 
often  agreeable  to  the  j)atient.  Finally,  the  limitation  of  motion 
cannot  })e  lessenetl  by  inclining  the  head  toward  the  muscle  that 
seems  to  be  most  contracted,  for  the  reflex  spasm  of  Pott's  disease 
limits  motion  in  every  direction.  As  a  rule,  the  diagnosis  is 
easily  made,  l)nt  in  ca.ses  complicated  by  suppuration  of  the  cer- 
vical glands  it  is  sometimes  impossible  to  exclude  Pott's  disease 
until  after  tlic  effc'ct  of  treatment  has  ))een  observed. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  653 

Disease  of  the  cervical  spine,  other  than  tuberculous,  is  com- 
paratively rare,  and  resembles  in  its  symptoms  Pott's  disease 
rather  than  torticollis.  Arthritis  of  the  suboccipital  articulations 
may  be  a  manifestation  of  rheumatism;  it  may  follow  infectious 
disease,  or  it  may  occur  as  an  isolated  infection.  It  is  of  sudden 
onset,  and  it  resembles  acute  spastic  torticollis,  except  that  all  the 
surrounding  muscles  are  affected  rather  than  a  particular  group; 
in  fact,  but  for  the  history  it  could  not  be  distinguished  from 
tuberculous  disease  of  this  region. 

Although  the  diagnosis  of  torticollis  is  simple,  it  is  not  always 
easy  to  determine  the  muscle  or  muscles  involved  in  the  contraction. 
The  effect  of  miilateral  contraction  of  the  different  muscles  is  as 
follows : 

The  sternomastoid  inclines  the  head  toward  the  contraction, 
displaces  it  toward  the  opposite  shoulder,  elevates  the  chin,  and 
turns  it  away  from  the  contracted  muscle. 

The  trapezius  has  much  the  same  action,  but  the  backward 
inclination  and  rotation  are  more  marked. 

The  action  of  the  complexus  resembles  that  of  the  trapezius, 
but  the  rotation  is  less. 

The  splenius  inclines  the  head  backward  and  toward  the  con- 
tracte;!  muscle,  but  does  not  turn  the  chin  in  the  opposite  direction. 

The  scaleni  have  the  same  action,  except  that  the  head  is  inclined 
forward. 

As  has  been  state:!,  in  acute  torticollis  several  muscles  are 
often  involve  1,  but  the  spasm  is  usually  greater  in  one  or  in  one 
group  than  in  another.  The  seat  of  greatest  contraction  may  be 
determined  by  the  deformity,  by  the  evident  spasm  that  resists 
reposition,  and  by  the  local  sensitiveness  on  palpation.  As  a 
rule,  when  the  primary  contraction  is  of  the  posterior  group  the 
deformity  is  more  marked  than  in  other  forms.  Bilateral  contrac- 
tion of  the  muscles  is  rare,  but  it  is  occasionally  seen  (Fig.  40!)). 

Treatment. — ^The  treatment  varies  according  to  the  cause  and 
with  the  duration  of  the  deformity.  Excluding,  for  the  present, 
the  rare  and  irregular  forms  of  wryneck  there  are,  from  the  re- 
medial standpoint,  two  forms  of  torticollis: 

1.  The  chronic  form,  in  which  the  local  pain  and  sensitiveness 
are  absent,  but  in  which  there  is  resistant  and  permanent  defor- 
mity. As  has  been  stated,  congenital  torticollis  is  included  in  this 
class. 

2.  The  acute  form,  in  which  die  distortion  is  of  short  dunitioji 
and  in  which  permanent  contraction  may  be  prevented. 


654  ORTHOPEDIC  SURGERY 

The  Treatment  of  Chronic  Torticollis.  By  Manipulation. — Con- 
genital torticollis,  if  of  moderate  degree,  can  be  overcome  in  early 
infancy  by  methodical  stretching  of  the  contracted  parts.  One 
person  fixes  the  arm  and  another  draws  the  head  gently  but  firmly 
in  the  direction  opposed  to  the  contraction,  over  and  over  again, 
meanwhile  massaging  the  tissues  of  the  neck.  The  procedure 
should  be  repeated  several  times  a  day;  it  causes  slight  momentary 
discomfort  if  properly  performed,  but  this  ceases  when  the  stretch- 
ing is  discontinued.  Care  should  be  taken  also  that  the  posture 
may,  as  far  as  possible,  favor  the  reduction  of  the  deformity; 
thus  while  the  child  is  in  the  mother's  arms  the  head  should  be 
supported,  and  when  asleep  the  pillow  may  be  arranged  in  a 
manner  to  prevent  the  improper  position.  In  this  way  the  torti- 
collis may  be  entirely  corrected  or  its  progress  may  be  checked 
until  more  effective  treatment  is  indicated. 

Hsematoma. — ^This  should  be  treated  by  massage  with  some 
bland  ointment;  if  it  is  accompanied  by  deformity  the  manipula- 
tion already  described  should  be  employed. 

In  the  great  majority  of  cases  of  congenital  torticollis  the  patient 
is  not  brought  for  treatment  until  the  deformity  has  become 
an  eyesore  to  the  parents.  The  contracted  muscle  is  then  usually 
an  inch  shorter  than  its  fellow,  the  disparity  increasing,  as  a  rule, 
with  the  growth  of  the  child.  In  such  cases  the  immediate  correc- 
tion of  the  deformity  is  indicated,  and  this  implies  in  most  instances 
diA-ision  of  the  contracted  parts  by  subcutaneous  tenotomy  or  by 
open  incision. 

By  Subcutaneous  Tenotomy. — If  the  deformity  is  comparatively 
slight  and  if  the  contraction  seems  to  be  limited  to  the  sterno- 
rnastoid  muscle,  and  particularly  to  its  sternal  portion,  one  may 
liope  to  overcome  the  most  resistant  part  of  the  contraction  by 
the  subcutaneous  operation.  Aside  from  the  possibility  of  wound 
infection,  wliich  at  the  present  time  is  an  argument  of  very  little 
weight,  subcutaneous  tenotomy  has  the  advantages  of  simplicity, 
apparent  freeflom  from  the  danger  which  parents  associate  with 
an  operation,  and  it  leaves  no  scar  behind.  It  is  inadequate, 
liowever,  for  the  correction  of  advanced  cases. 

The  patient  and  the  instruments  having  been  prepared  as  for  an 
ordinary  operation,  a  sand-bag  is  placed  beneath  the  shoulders  and 
the  })ead  is  inclined  so  that  tlie  contracted  muscle  is  thrown  into 
relief  beneath  the  skin.  The  sternal  insertion  of  the  tendon  is 
seizerl  with  two  fingers  and  the  tenotome  is  inserted  beside  it  and 
passed  l>eneath  it  at  a  point  about  an  inch  al)Ove  the  sternum. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  655 

It  is  then  divided  by  a  sawing  motion  of  the  knife.  Division  of 
this  part  of  the  muscle  in  this  situation  is  practically  free  from 
danger,  and  in  the  sligliter  degrees  of  deformity  one  can  by  vigor- 
ous manipulation  and  forcible  traction  overcome  the  resistance 
offered  by  the  other  tissues.  If  bands  of  fascia  resist  the  correc- 
tion, they  may  be  divided  by  superficial  nicking  with  the  tenotome 
in  the  lateral  region  of  the  neck.  As  a  rule,  however,  in  cases 
of  this  type  the  open  incision  is  to  be  preferred,  as  it  allows  the 
opportunity  for  free  division  of  the  contracterl  parts  with  less 
danger  of  injury  to  the  bloodvessels  and  nen-es  in  this  neighbor- 
hood. 

By  the  Open  Method. — ^The  incision  should  be  made  just  above 
the  clavicle  in  the  line  of  the  muscle  midway  between  the  sternal 
and  clavicular  insertion.  In  the  milder  cases  in  childhood  it  need 
be  little  more  than  an  inch  in  length.  A  director  may  be  passed 
beneath  the  tendon,  and  on  this  it  may  be  divided.  The  clavic- 
ular insertion  and  the  more  resistant  bands  of  fascia  may  be 
divided  as  they  appear. 

In  cases  of  very  great  deformity  in  the  adult  some  of  tlie  pos- 
terior as  well  as  the  lateral  muscles  are  involved.  In  such  instances 
the  contracted  parts  may  be  divided  at  the  upper  border  of  the 
neck  through  an  incision  from  the  mastoid  process  backward 
along  the  lower  border  of  the  scalp,  the  scar  being  concealed  by 
the  hair. 

Overcorrection  of  the  Deformity. — ^The  object  of  treatment  is  not 
only  to  straighten  the  head,  but  also  to  overcome  all  restric- 
tion of  motion  that  may  remain  after  the  division  of  the  more 
resistant  parts,  and  the  operation,  whether  open  or  subcutaneous, 
must  be  supplemented  by  a  vigorous,  methodical  stretching  of 
underlying  resistant  tissues.  Finally,  the  head  should  be  rotated 
in  the  opposite  direction,  the  aim  being  to  completely  overcome 
the  secondary  curvature  of  the  cervical  spine. 

It  may  be  stated  that  Lorenz  considers  it  possible  to  correct 
torticollis,  even  of  long  standing,  by  systematic  kneading  and 
stretching  without  previous  division  of  the  contracted  tissues,  but 
the  use  of  so  much  force  appears  to  be  undesirable  if  by  so  slight 
an  operation  it  may  be  avoided.  It  is  because  the  after  stretching 
is  so  important  that  the  upright  incision  is  to  be  preferred  to  one 
in  the  line  of  the  clavicle. 

After  all  resistance  to  passive  motion  has  been  overcome 
by  vigorous  manipulation  the  head  should  be  fixed  (hiring  the 
process  of  repair    in  the  overcorrected    position.      Thus    in  the 


656 


ORTHOPEDIC  SURGERY 


treatment  of  typical  torticollis  the  chin  should  be  turned  to  a 
point  over  the  middle  of  the  clavicle  on  the  operated  side,  and 
the  head  should  be  inclined  toward  the  opposite  shoulder,  while 
the  neck  is  held  in  the  median  line.  In  this  attitude  a  plaster 
ijandage  should  be  applied  surrounding  the  head  and  the  thorax. 
It  should  remain  until  all  local  sensitiveness  has  disappeared,  and 
until  the  tendency  toward  deformity  has  been  checked.  Fixation 
in  the  overcorrected  position  is  very  important  in  childhood,  as 
an  aid  in  overcoming  the  deformity  habit,  but  it  may  be  dispensed 
with  in  the  treatment  of  adults  (Fig.  412). 


Fig.   412 


Torticollis,  left,  showing  the  method  of  fixing  the  iiead  in  the  overcorreuted  position. 

After  operation. 

"^rhe  plaster  bandage  is  usually  retained  from  four  to  eight 
weeks.  When  it  is  removed,  massage,  manipulation,  and  gymnastic 
training  are  indicated.  Twice  a  day  the  head  should  be  forced  to 
the  extreme  limit  of  overcorrection.  Traction  on  the  neck  in 
self-suspension  l)y  means  of  the  sling  used  in  the  application  of 
the  plaster  jacket,  a  regular  system  of  exercises  for  tlic  muscles 
of  the  neck  and  back,  and  supervision  of  the  habitual  postures  will 
usually  assure  a  complete  cure.     If,  however,  the  deformity  habit 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  657 

is  strong  so  that  the  head  has  a  marked  tendency  to  resume  the 
former  attitude,  some  support  is  indicated.  A  simple  and  effec- 
tive support  is  the  jury-mast  as  used  in  the  treatment  of  Pott's 
disease  with  the  plaster  jacket  or  attached  to  a  brace.  In  the 
treatment  of  children  a  band  of  elastic  tape  arranged  to  draw  the 
head  toward  the  shoulder  as  suggesterl  by  Sayre,  or  a  Thomas 
collar,  may  be  sufficient. 

As  has  been  stated,  the  necessity  for  support,  provi(!ed  the 
deformity  has  been  thoroughly  overcorrected,  depends  upon  the 
care  that  is  to  be  exercised  in  the  after-treatment.  When  exer- 
cises and  massage  can  be  efficiently  employed,  the  support  is  not 
essential.  In  other  cases  it  may  be  worn  for  several  months  with 
advantage. 

The  principles  of  the  treatment  of  the  chronic  or  painless  form 
of  torticollis  that  have  been  outlined  apply  to  the  acquirefl  as 
well  as  to  the  congenital  form,  when  adaptive  shortening  has 
replaced  active  contraction.  Acquired  torticollis  is,  in  most 
instances,  however,  a  preventable  deformity;  thus  operative 
treatment  would  be  rarely  required  had  the  patient  received 
proper  treatment. 

The  Treatment  .of  Acute  Torticollis. — The  insignificant  form  of 
torticollis  called  stiff  neck  may  be  treated  by  hot  applications;  a 
firm,  thick  collar  of  flexible  cotton  stiffened  by  several  layers  of 
adhesive  plaster  is  an  agreeable  support  in  the  more  painful  cases. 

In  acute  spastic  torticollis  the  cramp-like  contraction  of  the 
muscles  is  secondary  to  irritation  elsewhere.  This,  one  should 
always  try  to  remove,  and,  as  has  been  stated,  the  general  con- 
dition of  the  patient  often  requires  treatment  as  well.  But  the 
important  indication  is  to  support  the  head  in  order  to  relieve  the 
pain  and  to  correct  the  distortion.  In  the  early  stage  the  support 
of  the  collar  that  has  been  described  may  be  sufficient,  but,  as  a 
rule,  patients  of  this  class  are  not  seen  until  the  distortion  has 
persisted  for  weeks  or  months  even,  so  that  a  more  efficient 
form  of  support  is  required — such  is  the  plaster  jacket  and  jury- 
mast.  The  elastic  tension  of  this  appliance  overcomes  the 
spasm  and  relieves  the  discomfort  and  apprehension  which  have 
lowered  the  vitality  of  the  patient  (Fig.  51).  If  the  spasm  is 
the  result  of  the  irritation  of  enlarged  or  suppurating  cervical 
glands,  as  is  often  tlie  case,  the  rest  afforded  by  the  brace  is  an 
effective  treatment  of  the  cause  as  well  as  of  its  effect,  and  if 
suppuration  is  present  this  support  is  most  convenient  for  the 

dressing  that  may  be  required.     WliQii  the  acute  symptoms  and 

42  r      . 


658  ORTHOPEDIC  SURGERY 

the  deformity  have  been  reHeved,  manipulation  and  exercises  may 
employed  in  the  manner  already  described. 

In  cases  of  longer  standing,  particularly  when  the  posterior 
muscles  are  involved,  the  deformity  may  be  forcibly  corrected 
under  anisesthesia,  and  the  head  may  then  be  jfixed  m  a  plaster 
dressmg  in  the  manner  already  described.  This  treatment  may 
be  employed"  at  an  earlier  stage  m  selected  cases.  As  a  rule, 
when  deformity  has  been  allowed  to  persist  for  six  months  or  more, 
its  rectification  will  require  division  of  the  more  resistant  tissues. 

Spasmodic  Torticollis. 

Spasmodic  torticollis,  a  form  of  convulsive  spasm  of  the 
muscles  of  the  neck  that  is  somewhat  similar  in  its  general  char- 
acteristics to  writer's  camp,^  must  not  be  confounded  with  the 
acute  torticollis  of  childhood,  in  which  tonic  spasm  of  the  affected 
muscles,  due  usually  to  some  well-defined  irritation  of  the 
peripheral  nerves,  is  the  characteristic.  Spasmodic  torticollis  is 
an  affection  of  adult  life.  Of  32  cases  collected  by  Richardson 
and  Walton,^  but  two  were  in  patients  less  than  twenty  years  of 
age.  The  sexes  are  equally  liable  to  the  affection,  and  the  con- 
traction is  as  frecjuent  on  one  side  as  on  the  other. 

The  onset  of  the  affection  is  usually  gradual.  The  first  symp- 
toms are  usually  of  stiffness  and  discomfort  in  the  muscles 
of  the  neck;  a  "drawing  sensation"  and  a  momentary  twitch- 
ing or  slight  contraction  which  draws  the  head  to  one  side. 
These  symptoms  increase  slowly  until  the  head  is  habitually 
inclined  in  the  attitude  of  torticollis.  For  a  time  the  patient  can 
correct  the  position  voluntarily,  or  by  supporting  the  head  with 
the  hand  can  restrain  the  twitching  of  the  muscles,  but  in  well- 
established  cases  the  head  is  persistently  inclined  to  one  side  and 
the  convulsive  spasm  is  uncontrollable.  This  latter  symptom  is 
the  most  marked  peculiarity  of  the  affection ;  at  intervals  the  muscles 
begin  to  twitch,  and  the  head  finally  drawn  by  tlie  convulsive 
contraction  into  an  attitude  of  extreme  deformity.  As  the  muscles 
most  often  affected  are  the  sternomastoid  and  trapezius  the 
attitude  is  usually  one  of  typical  torticollis.  The  spasmodic 
clonic  contractions  may  involve  the  muscles  of  the  face  or  of 
the  chest  even.  They  are  more  marked  when  the  patient  is 
excited  or  when  sudden  movements  are  necessary.     As  a  rule, 

1  SpaHmodic  torticollis  is  defineJ  by  Walton  as  a  "disorder  of  the  cortical  centres  for 
rotation  of  the  head,"    American  Journal  of  the  Medical  Sciences,  March,  1898. 
•  American  Journal  of  the  Medical  Sciences,  January,  1895. 


CONGENITAL  AND  ACQUIEEU  TORTICOLLIS  659 

patients  complain  of  neuralgic  pain  in  the  head  and  neck,  aggra- 
vated by  the  cramp-like  contractions. 

Etiology  and  Pathology.  — ^The  etiology  is  obscure.  Many  of 
the  patients  present  a  neurotic  family  or  personal  histor}^  and 
overwork,  shock  to  the  nervous  system,  and  the  like  are  cited  as 
prelisposing  causes.  The  affection  has  been  compared  to  writer's 
cramp,  as  in  certain  instances  the  spasm  appeared  to  be  caused  by 
constrained  positions  of  the  head  necessitated  by  certain  occupa- 
tions, aggravated,  it  may  be,  by  the  strain  of  defective  eyesight. 

The  affected  muscles  may  be  hypertrophied  from  constant 
activity,  and  in  the  later  stages  of  the  affection  they  are,  as  a 
rule,  permanently  shortened.  No  characteristic  changes  in  the 
nerves  or  in  the  central  nervous  system  have  been  recorded. 

Prognosis. —There  is  little  tendency  toward  spontaneous  re- 
covery. As  a  rule,  the  spasm  becomes  more  constant  and  other 
muscles  become  involved. 

Treatment.  — It  is  perhaps  unnecessary  to  state  that  the  general 
condition  of  the  patient  and  the  possible  local  and  general  causes 
of  the  spasm  should  receive  consideration.  As  a  rule,  however, 
the  patient  will  have  exliausted  both  constitutional  and  local 
treatment  before  coming  under  observation. 

In  the  mild  and  early  cases  the  avoidance  of  predisposing 
causes  combined  with  massage,  systematic  muscle  training,  and 
in  exceptional  mstances  mechanical  support  may  be  of  service; 
but  in  the  chronic,  severe,  and  persistent  cases  of  this  class  the 
resection  of  nerves  supplying  the  affected  muscles  has  alone  proved 
to  be  efficient.  If  the  spasm  is  limited  to  the  sternomastoid  and 
trapezius  muscles,  resection  of  the  spinal  accessory  nerve  may  be 
sufficient;  but  if  other  muscles  are  involved  or  if  the  spasm  recurs 
after  the  origmal  operation,  the  removal  of  the  posterior  branches 
of  the  upper  cervical  nerves,  together  with  extensive  division  of 
tlie  contracterl  muscles  upon  the  same  side  and  sometimes  upon 
the  opposite  side  also,  may  be  required. 

Resection  of  the  spinal  accessory  nerve  was  first  performed  by 
Campbell  de  Morgan,  of  London,  in  1S66,  and  since  then  the 
operation  has  been  repeated  many  times  by  other  surgeons,  with 
temporary  or  permanent  benefit  to  the  patients.  According  to 
Petit,  of  26  patients  so  treated  13  were  cured  and  7  were  perma- 
nently improved.  In  5  others  the  benefit  was  but  temporary, 
and  1  died  from  erysipelas  following  the  operation.^ 

1   L'Union  Mddicale,  July  9,  1897. 


660  OR THOPEDIC  S  UB  GEB  Y 

The  Operation, — The  spinal  accessory  nerve  passes  dowTiward 
and  backward  from  the  jugular  foramen  and  enters  the  anterior 
border  of  the  sternomastoid  muscle  at  a  point  about  one  and  a 
half  inches  below  the  tip  of  tlie  mastoid  process.  At  this  point 
it  should  be  exposed.  Dr.  E.  Eliot,  Jr.,  from  a  special  study  of 
the  course  and  relations  of  tlie  nerve,  suggests  the  following 
method  :^ 

"The  incision  should  be  generous,  for  the  nerve  is  situated  at 
a  considerable  depth,  and  should  extend  from  the  mastoid  process 
above  downward  to  one  or  two  inches  beyond  the  angle  of  the 
jaw.  The  anterior  edge  of  the  sternomastoid  should  then  be 
exposed.  In  the  upper  part  of  the  wound  the  posterior  and 
inferior  portion  of  the  parotid  gland  may  have  to  be  drawn  for- 
ward, although  usually  it  does  not  overlap  the  muscle.  ^Vhen 
this  is  done  it  is  comparatively  easy  to  expose  by  blunt  dissection 
the  transverse  process  of  the  atlas,  as  it  lies  directly  below  the 
mastoid  process  above,  while  immediately  in  front  of  this  bony 
prominence,  and  running  downward  and  forward  from  the  mas- 
toid process  toward  the  angle  of  the  jaw  is  the  posterior  belly  of 
the  digastric.  Behind  this  lie  the  main  vessels  of  the  neck,  with 
the  spinal  accessory  nerve  emerging  from  the  jugular  foramen, 
and  the  operator  is  certain  that  no  harm  can  be  done  to  these 
structures  as  long  as  he  remains  superficial  to  the  digastric  belly, 
which  in  its  turn  lies  at  a  considerable  depth — in  fact,  at  about 
the  level  of  the  transverse  process  of  the  atlas. 

"Owen  and  P^tit  have  drawn  attention  to  the  fact  that  the 
nerve  usually  enters  the  mastoid  muscle  at  a  point  opposite  the 
angle  of  the  jaw.  I  have  found,  however,  in  a  large  majority  of 
cases  that,  on  leaving  the  internal  jugular  it  assumes  a  definite 
relationship  with  the  transverse  process  of  the  atlas.  Never 
above  it,  sometimes  directly  over  it,  usually  a  fraction  of  an  inch  in 
front  of  its  most  prominent  part,  the  nerve  may  easily  be  detected 
in  the  small  amount  of  connective  tissue  that  envelops  it,  and 
from  this  point  to  its  entrance  into  the  belly  of  tlie  muscle  it  may 
be  isolate  1  witli  safety,  and  treated  by  any  suitable  proceckire. 
If,  exceptionally,  it  should  escape  detection  the  anterior  border 
of  the  muscle  should  be  drawn  sharply  backward  at  a  point  oppo- 
site t'le  angle  of  the  jaw,  the  nerve  in  this  way  put  on  the  stretch, 
and  by  blunt  dissection  in  the  adipose  tissue  that  separates  the 
under  surface  of  the  muscle  from  the  sheath  of  the  vessels 
the  nerve  may  be  readily  exposerl.     Usually  the  nerve  passes 

'  AnnalH  of  Surgery,  May,  1895. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  661 

from  under  the  posterior  belly  of  the  digastric,  at  a  point  just 
in  front  of  the  transverse  process  of  the  atlas,  to  a  point  on  the 
deep  surface  of  the  muscle  just  behind  its  anterior  margin  oppo- 
site the  angle  of  the  inferior  maxilla.  It  is  sometimes  accom- 
panied by  a  small  artery  and  vein,  the  latter  easily  visible,  the 
former  a  branch  of  the  occipital.  Rarely  the  nerve  lies  at  a  con- 
siderable distance  from  the  transverse  process  of  the  atlas;  in  one 
case  as  much  as  half  an  inch  anteriorly.  Here  the  nerve  could 
be  found  at  its  entrance  into  the  muscle,  the  landmark  of  the 
transverse  process  having  failed  to  localize  its  situation." 

Richardson  suggests  that  if  the  nerve  is  not  readily  found  its 
position  may  be  ascertained  by  drawing  the  finger-nail  firmly 
across  the  bottom  of  the  wound,  a  sharp  contraction  following 
pressure  upon  it.  The  nerve  having  been  isolated  a  section  of  an 
inch  should  be  removed.  Richardson  advises  in  addition  vigor- 
ous stretching  of  both  extremities.  After  division  of  the  nerve 
the  spasmodic  contraction  relaxes  and  the  muscles  become  flaccid, 
allowing  the  head  to  be  brought  to  the  normal  position,  or  if  the 
deformity  has  become  permanent  the  contracted  parts  may  be 
divided  as  in  the  ordinary  form.  Fixation  of  the  head  is  not,  as 
a  rule,  required.  The  operation  should  be  supplemented  by 
massage  and  by  muscle-training.  If  the  spasm  has  been  confined 
to  the  muscles  supplied  by  the  spinal  accessory  nerve,  the  treat- 
ment may  be  permanently  successful,  but  in  many  instances  the 
spasm  may  recur  in  other  muscles.  Of  these,  the  posterior  group 
of  the  opposite  side  is  more  often  affected,  and  a  similar  opera- 
tion for  resection  of  the  posterior  branches  of  the  upper  cervical 
nerves  may  be  indicated.  This  has  been  performed  with  success 
by  Smith,  of  London;  Keen,  Richardson,  and  others.  According 
to  Smith,^  the  operation  should  be  conducted  as  follows:  An 
incision  is  carried  downward  from  the  occiput  about  three  inches 
in  length,  parallel  to  and  one  inch  from  the  spinous  processes.  It 
is  continued  through  the  trapezius  to  the  edge  of  the  splenius. 

The  complexus  is  then  divided  and  the  posterior  branches  of  the 
nerves  are  exposed;  those  of  the  three  upper  nerves  which  supply 
the  posterior  rotators  are  then  resected. 

Keen^  operates  in  a  somewhat  different  manner,  by  a  transverse 
incision  two  and  a  half  inches  in  length  from  the  middle  line  of 
the  neck  on  a  level  with  a  point  one-half  an  inch  below  the  level 
of  the  lobule  of  the  ear.  The  trapezius  is  divided  transversely, 
afterward   the  complexus,  care  being  taken  to  spare  the  great 

1  Spasmodic  Wryneck,  London,  1891.  -  Annals  of  Surgery,  Januivry,  1891. 


662  OR  THOPEDIC  S  UR  G  ER  Y 

occipital  nerve.  The  posterior  branch .  of  the  second  cervical 
nerv'e  is  then  resected;  the  suboccipital  nerve  is  then  looked  for 
in  the  suboccipital  triangle,  traced  down  to  the  spine,  and  divided. 
The  external  trunk  of  the  posterior  division  of  the  third  occipital 
nerve  is  then  exposed  below  the  great  occipital  and  divided  close 
to  the  bifurcation  of  the  nerve  trunk;  thus  the  nerve  supply  of 
the  chief  posterior  rotators,  the  splenius  capitis,  the  rectus  capitis, 
posticus  major,  and  the  obliquus  inferior  is  removed. 

The  paralysis  that  follows  even  such  extensive  operations 
seems  to  inconvenience  the  patient  but  slightly,  while  the  relief 
from  deformity  and  from  the  constant  spasm  is  a  more  than  suffi- 
cient compensation  for  whatever  weakness  or  disability  may  result. 

The  folio wmg  are  the  conclusions  of  Richardson  and  Walton:^ 

1.  Palliative  treatment,  whether  by  drugs,  apparatus,  or  elec- 
tricity, will  rarely  prove  successful  in  well-established  spasmodic 
torticollis. 

2.  ■Massage  may  prove  of  value  in  comparatively  recent  cases. 

3.  Resection  affords  practically  the  only  rational  remedy. 

4.  Operation  on  the  spinal  accessory  nerve  may  afford  relief, 
even  if  other  muscles  than  the  sternocleidomastoid  are  affected. 
On  the  other  hand,  the  affection  previously  limited  to  the  sterno- 
cleidomastoid may  spread  to  other  muscles  in  spite  of  this  opera- 
tion. 

5.  No  fear  of  disabling  paralysis  need  deter  us  from  recom- 
mending operation,  as  the  head  can  be  held  erect  even  after'the 
most  extensive  resection. 

6.  The  most  common  combination  of  spasm  is  that  involving 
the  stemomastoid  on  one  side  and  the  posterior  rotators  on  the 
other,  the  head  being  held  in  the  position  of  stemomastoid  spasm 
with  the  addition  of  retraction  through  the  greater  power  of  the 
posterior  rotators. 

7.  It  seems  advisable  in  most  cases  to  give  preference  to  the 
resection  of  the  spinal  accessoiy  as  the  preliminary  procedure. 

In  a  later  communication  Richardson  and  Walton^  report  very 
satisfactory  final  results  on  cases  treated  by  resection  of  nerves 
supplying  the  muscles  that  were  affected  by  the  spasm  on  one  or 
both  sides,  combined  with  complete  division  of  the  muscles  as 
well,  when  permanent  contraction  was  present. 

Kalmus''  has  reviewed  the  literature  of  the  sul)ject.  In  11 
cases  of  siin[>le  stretching  of  tlie  spinal  accessory  nerve  3  were 

'   Annals  of  .Surgery,  January,   1891. 

-  American  Journal  of  the  Medical  Sciences,  1890. 

■'  Zur  Opcrativ  Hehand.  (japut.  Ohst.  Spasl.icum,  Heitra^e  zur  kliii.  Cliir.,  1900,  Bd.  xxiv. 


CONGENITAL  AND  ACQUIRED  TORTICOLLIS  G63 

cured.  In  68  cases  the  nerve  was  resected;  of  these  23  were 
cured  and  20  were  improved.  In  4  there  was  no  improveroent 
and  in  1  the  patient  died.  In  15  cases  the  resection  of  the  nerve 
was  supplemented  by  division  of  cervical  nerves;  10  of  these 
were  cured  and  3  were  improved.  In  2  others  the  sternomastoid 
muscle  was  divided. 


Irregular  and   Exceptional  Forms  of   Torticollis. 

Paralytic  Torticollis. — One  or  more  of  the  muscles  of  the  neck 
may  be  paralyzed,  as  from  anterior  poliomyelitis,  and  thus  a 
deformity,  due  at  first  to  simple  weakness  and  later  to  the 
permanent  effects  of  the  disability,  may  be  the  result. 

Diphtheritic  Paralysis  and  Torticollis. — The  muscles  of  the 
neck  may  be  involved  in  paralysis  following  diphtheria.  In  this 
form  the  trapezii  muscles  are,  as  a  rule,  affected,  so  that  the  head 
droops  forward,  but  occasionally  the  paralysis  may  be  accompanied 
by  contraction  of  one  of  the  sternomastoids.  The  history,  the 
evident  wealoiess,  and  the  paralysis  of  the  soft  palate  or  other 
parts,  which  is  often  present,  usually  make  the  diagnosis  clear. 

Cervical  Opisthotonos. — In  the  course  of  certain  forms  of  dis- 
ease of  the  nervous  system,  for  example,  cerebrospinal  or  basilar 
meningitis,  the  head  may  be  drawn  backward  by  spasm  of  the 
posterior  muscles.  A  slight  degree  of  the  same  deformity  is 
sometimes  seen  in  ill-nourished  infants  not  suffering  from  serious 
disease.  This  and  the  preceding  distortion  are  of  some  impor- 
tance, because  they  may  be  mistaken  for  symptoms  of  Pott's 
disease  and  they  have  been  described  in  that  connection.  (See 
page  62.) 

Rhachitic  TorticolUs. —During  the  course  of  acute  rhachitis, 
particularly  when  the  characteristic  deformity  of  the  lower  part 
of  the  spine  is  well-marked,  the  head  may  be  tilted  backward 
usually  as  a  compensatory  attitude,  but  occasionally  slight  spasm 
of  the  posterior  muscles  may  increase  tlie  distortion;  so,  also, 
when  lateral  deviation  of  the  spine  is  present  due  to  rhachitis  the 
neck  may  participate  in  the  deformity  as  in  other  forms  of  rotary 
lateral  curvature.  This  is  not  torticollis,  however,  in  the  proper 
sense. 

Ocular  Torticolhs. — Several  cases  have  been  recorded  in  whicli 
the  head  was  habitually  liel  1  in  a  distorted  attitude  because  of 
defective  vision  or  irregularity  in  the  action  of  the  muscles  of  the 


664  ORTHOPEDIC  SURGERY 

eyes.     This   is,   however,    rather   an    improper   attitude   than   a 
variety  of  true  torticolHs^  (Fig.  169). 

Psychical  Torticollis. —A  distortion  of  the  head,  apparently 
due  to  the  mability  of  the  patient  to  control  the  muscles  of  the 
neck,  has  been  described  by  Brissaud.-  The  deformity  is  not 
due  to  muscular  spasm,  since  it  can  be  corrected  by  the  pressure 
of  a  finger  on  the  head.  The  condition  is  called  by  Brissaud  a 
local  paralysis  of  the  will — a  form  of  neurosis  allied  to  neuras- 
thenia, epilepsy,  and  functional  spasm. 

1  Medical  News,  June  11,  1898,  p.  772,  -  Thfese  de  Paris,  1894. 


CHAPTER   XX. 


DISABILITIES  AND  DEFORMITIES  OF  THE   FOOT. 
General  Description  of  the  Foot  and  of  its  Functions. 


The  function  of  the  foot  is  twofold:  to  serve  as  a  passive 
support  of  the  weight  of  the  body,  and  as  an  active  lever  to  raise 
and  propel  it.  For  the  proper  performance  of  these  functions 
it  is  constructed  to  permit  elasticity  under  pressure,  and  an 
alternation  of  attitudes  under  strain,  that  protect  it  from  injury. 

The  Arches. —The  most  noticeable  peculiarity  of  the  foot  is 
the  arrangement  of  its  arches.  As  has  been  suggested  by  Ellis 
and  others,  the  construction  and  shape  of  the  arched  part  of  the 


Fig.  413 


Longitudinal  section  of  the  cast  of  the  arch  at  the  point  A  in  Fig.  414.  A,  the  astragalo- 
navicular  junction;  B,  the  internal  tuberosity  of  the  os  calos;  C,  the  head  of  the  first  meta- 
tarsal bone. 

foot  may  be  better  understood  by  considering  it  as  half  of  the 
arch  formed  by  the  two  feet.  This  complete  arch  may  be  demon- 
strated by  making  an  imprint  of  the  apposed  feet  in  plaster-of- 
Paris.  The  plaster  cast  which  represents  it  will  appear  in  shape 
somewhat  like  an  inverted  saucer,  the  part  of  each  foot  tliat  rests 
upon  the  ground  forming  half  of  an  irregular  ring.  If  the  plaster 
cast  is  sawed  into  equal  sections  it  will  be  seen  that  the  liigliest 
or  thickest  part  of  each  division  is  at  the  astragalonavicuhir  junc- 
tion; from  this  point  the  arch  descends  sharply  to  the  tuberosities 
of  the  OS  calcis,  and  gradually  to  the  outer  border,  beneath  the 
cuboid  bone,  and  to  the  metatarsophalangeal  joints  (Fig.  413), 
A  cross-section  of  the  cast  will  show  the  contour  of  what  is  some- 
times called  the  transverse  arch  (Fig.  414),  while  the  section 
through  the  long  diameter  will  demonstrate  the  shape  of  the 


eee 


ORTSOPEDIC  S UR GER Y 


longitudinal  arch.  In  descriptions  of  the  longitudinal  arch  it  is 
often  divided  into  two  parts,  of  which  the  outer  division  is  formed 
by  the  os  calcis,  the  cuboid,  and  the  two  outer  metatarsal  bones. 
Of  this  outer  arch,  the  highest  point  is  at  the  calcaneocuboid 
articulation  (Fig.  415),  and  although  it  is  normally  a  permanent 
arch,  yet  the  soft  tissues  are  forced  downward  beneath  it  when 


Fig.  414 


Cross-section  of  the  cast  of  the  arches  of  the  apposed  feet.     A,  the  internal  and  inferior 
surface  of  the  astragalonavicular  junction. 

weight  is  borne,  so  that  the  outer  border  of  the  foot  makes  an 
imprmt  throughout  its  entire  length,  as  contrasted  with  the  inner 
and  deeper  arch  formed  by  the  os  calcis,  the  astragalus,  the 
navicular,  the  cuneiform,  and  the  three  inner  metatarsal  bones 
(Fig.  416).  This  division,  although  an  artificial  one,  serves  to  call 
attention  to  the  fact  that  the  outer  or  lower  arch  is  more  solidly 

Fig.  415 


The  bones  of  the  riglit  foot,  viewed  from  the  outer  side.     (Testut,  from  Gerrish's  Anatomy.) 

Ijracerl,    and,    therefore,    better   adapted   for   continuous   weight 
bearing  than  is  tlie  higher  and  more  elastic  inner  arch. 

The  diagram  of  the  longitudinal  arch,  showing  its  sharp 
descent  from  the  highest  point  to  tlie  centre  of  the  heel,  indicates 
that  the  heel  is  well  adapted  for  weight  bearing,  wliile  the  long 
anterior  pillar  composed  of  several  bones  is  less  strong  but  more 
elastic;   thus   one   instinctively   extends   the   foot   in   descending 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     667 

stairs,  for  example,  to  avoitl  the  unpleasant  jar  of  direct  shock 
received  upon  the  heel.  Of  this  anterior  pillar,  the  third  meta- 
tarsal bone  is  the  most  direct  support,  while  the  more  movable 
first  and  fifth  metatarsals,  more  under  muscular  control,  aid  in 
balancing  the  weight  and  sustaining  it  in  the  different  attitudes. 
Both  divisions  of  the  longitudinal  arch  are  permanent  arches, 
but  there  are  two  others  which  are  obliterated  under  weight — one 
of  these  is  that  formed  by  the  heads  of  the  metatarsal  bones,  the 
anterior  metatarsal  arch.  In  the  unweighted  foot  the  second  and 
third  metatarsophalangeal  articulations  occupy  a  higher  plane 
than  their  fellows,  but  when  the  erect  posture  is  assumed  the 
anterior  arch  is  depressed  to  allow  all  the  metatarsal  heads  to 
bear  their  share  of  the  weight.  The  other  arch  is  formed  by  the 
internal  border  of  the  foot,  which  curves  slightly  outward,  so  that 

Fig.  416 


The  bones  of  the  right  foot,  viewed  from  the  inner  tide.     (Testut,  from  Gerrish's  Anatomy.) 

when  the  two  feet  are  placed  side  by  side  an  interval  remains 
between  them,  widest  at  the  highest  point  of  the  longitudinal 
arch,*as  is  shown  in  the  diagram  by  the  upright  section  which 
divides  the  cast  of  the  two  soles  from  one  another,  the  internal 
arch  (Fig.  414).  ^Vhen  the  weight  is  borne  this  curved  contour 
of  the  foot  becomes  straighter,  or  is  obliterated,  or  is  even  trans- 
formed to  an  arch  whose  convexity  is  internal  (Fig.  434). 

The  Foot  as  a  Passive  Support. — ^The  foot  is  supported  by 
the  muscles,  by  ligaments,  and  by  the  strong  plantar  fascia  that 
covers  in  the  sole,  \\lien  the  foot  is  actively  used  it  is  in  great 
part  supported  by  the  muscles,  but  when  it  serves  as  a  passive 
support,  as  in  standing,  the  ligaments  bear  the  greater  j)art  of 
the  strain,  and  its  normal  elasticity  allows  the  bearing  surface 
to  expand  as  the  arches  are  sliglitly  depresse  1.  If  this  elasticity 
is  diminished,  the  supports  of  the  arch   are  subjected   to  abnor- 


668  ORTHOPEDIC  SURGERY 

mal  pressure  and  the  individual  may  suffer  from  sensitive  corns 
or  calloused  skin  beneath  the  bones  (Fig.  462).  Or  if  the  liga- 
ments permit  abnormal  expansion  the  arches  may  become  per- 
manently depressed,  and,  as  a  result,  the  range  of  motion  neces- 
sary to  the  proper  functional  use  of  the  foot  may  be  permanently 
restricted  (Fig.  436). 

AMien  the  statement  is  made  that  the  foot  broadens  and  that  the 
arches  are  slightly  depressed  under  weight,  it  must  not  be  under- 
stood that  the  longitudinal  arch  is  simply  flattened  by  direct 
pressure  and  by  elongation  of  elastic  ligaments  and  fascia.  Liga- 
ments and  fascia  are  not  elastic  in  this  sense,  and  they  are  not,  in 
the  normal  foot,  overstretched.  The  change  in  contour  is  the 
effect  of  normal  motion  in  the  joints  of  the  foot,  by  which  it  is 
placed  in  the  most  favorable  attitude  for  weight  bearing  without 
muscular  exertion — tlie  so-called  attitude  of  rest. 

Of  the  changes  of  contour  that  distinguish  the  foot  used  as  a 
passive  support  from  the  one  that  bears  no  weight,  the  most 
significant  is  the  obliteration  of  the  outward  curve  of  its  internal 
border.  This  change  is  due  to  the  fact  that  the  astragalus,  bear- 
ing the  leg,  rotates  inward  and  do^^'nward  on  the  os  calcis  until 
it  is  checked  by  the  resistance  of  the  ligaments  and  by  the  inter- 
locking of  the  bones.  The  head  of  the  astragalus  thus  becomes 
slightly  prominent,  the  inner  border  of  the  foot  is  depressed,  and 
an  attitude  is  attained  in  which  the  weight  of  the  body  may  be 
supported  with  but  slight  muscular  exertion.  In  this  attitude  of 
rest,  as  von  ]\Ieyer  has  explained,  there  is  general  fixation  of 
joints  of  the  lower  extremity  which  makes  support  possible  with 
the  least  muscular  exertion.  The  pelvis  tilts  slightly  backward 
until  tension  is  brought  upon  the  anterior  part  of  the  capsule  of 
the  hip-joint;  the  femur  rotates  slightly  inward  on  the  tibia, 
which  in  turn  falls  slightly  inward  upon  the  everted  foot.  To 
unlock  the  joints  the  pelvis  must  be  tilted  forward  or  the  hip 
must  be  flexe.l. 

The  Foot  in  Activity. —The  second  function  of  the  foot  is  as 
a  lever  to  raise  and  to  propel  the  borly.  The  calf  muscles  supply 
the  power  and  the  heads  of  the  metatarsal  bones  serve  as  the 
fulcrum  on  which  the  weight  is  to  be  lifted.  \\Tien  the  foot  is 
use]  as  a  lever,  it  should  he  held  in  such  relation  to  the  leg  that 
the  line  of  weight,  passing  downward  through  the  centre  of  the 
knee  and  ankle-joints,  is  continued  over  the  second  toe  or  prac- 
tically the  centre  of  the  foot.  As  the  body  is  lifted  over  the  ful- 
crum the  leg  is  turned  outward  in  its  relation  to  the  forefoot, 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     669 

because  the  inner  side  of  the  fulcrum,  formed  by  the  first  meta- 
tarsal bone,  is  longer  than  its  outer  side;  thus  the  strain  is  directed 
toward  the  outer  and  stronger  side  of  the  foot  (Fig.  417). 

In  the  proper  walk,  which  is  the  best  illustration  of  the  lever- 
age function,  the  feet  should  be  held  practically  parallel  to  one 
another,  so  that  the  line  of  strain  may  fall  through  the  centre  of 
the  foot.  As  one  foot  is  advanced  it  first  bears  weight  momen- 
tarily on  the  heel,  then  upon  its  outer  border;  the  heel  is  then 
raised,  and  the  body  is  lifted  over  the  toes,  the  great  toe  giving 
the  final  impulse  to  the  step,  so  that  if  the  walker  is  looked  at 


Fig.  417 


Fig.   418 


Illustrating  the  involuntary  adduction  The  improper  attitude  of  outward  rotation, 

of  the  forefoot,  due  to  the  obliquity  of  in  which  there  is  disuse  of  the  leverage  func- 

the  bearing  surface  of   the  metatarsus,  tion. 
in  the  proper  attitude  for  walking. 

from  behind  he  appears  to  be  in-toeing  at  the  termination  of 
each  step.  Thus,  during  the  walk,  there  is  an  alternation  of 
postures,  and  the  foot,  under  muscular  control,  a.ssumes  the 
attitudes  most  opposed  to  that  of  passive  support. 

Improper  Postures. — ^The  alternation  of  postures  and  the  lever- 
age action  of  the  foot  are  by  no  means  necessary  to  simple  pro- 
gression; for  example,  both  feet  miglit  be  fixed  in  plaster  bantlages, 
yet  walking  would  be  possible,  just  as  it  is  possible  on  two  wooden 
legs.  Indeed,  an  approximation  to  such  a  manner  of  walking  is 
often  seen,  in  which  the  feet  are  practically  held  in  the  passive 


670 


ORTHOPEDIC  SUBGEBY 


attitude,  the  weight  bemg  borne  upon  tlie  heels.  Such  a  walk 
is  necessarily  jarring  and  ungraceful,  and  if  it  is  not  the  result 
of  weakness  and  deformity  it  predisposes  to  them  because  of  the 
disuse  of  proper  function. 

One  means  of  makuig  the  leverage  function  difficult  is  the 
custom  of  turning  the  feet  outward.  Outward  rotation  of  the 
limbs  is  normal  in  the  passive  attitude  because  it  increases  the  base 
of  support  and  thus  relieves  the  muscles.  On  this  very  account 
it  is  the  improper  attitude  for  activity  because  the  strain  falls 
upon  the  mner  border  of  the  foot,  or  to  the  inner  side  of  the  ful- 
crum,  and  makes  the  proper  exercise  of  muscular  power  and 


Fig.  419 


Fig.  420 


A^ 


Voluntary  dorsal  flexion.  Voluntary  plantar  flexion. 

In  these   attitudes  the  astragalus  moves  with  the  foot  upon  the  leg  bones,  as  contrasted 
with  aclduction  and  abduction,  in  which  the  centre  of  motion  is  below  the  astragalus. 

alternation  of  postures  impossible.  In  other  words,  the  attitude 
normal  when  the  foot  is  used  as  a  passive  support  is  abnormal 
when  it  is  in  active  use. 

The  Movements  of  the  Foot. — ^The  junction  between  the  foot 
and  the  leg  is  made  by  means  of  tlie  astragalus,  a  bone  which  is 
not  intimately  connected  with  either  part,  since  it  moves  upon 
the  leg  and  upon  the  foot,  and  to  it  no  muscles  are  attached. 

The  primary  movements  of  the  foot  are  four  in  number — dorsal 
flexion,  plantar  flexion,  adduction,  abduction. 

SimT)le  dorsal  and  plantar  flexion  are  confined  to  the  ankle- 
joint,  but  extreme  plantar  flexion  is  combined  with  slight  adduc- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOl      671 

tion,  and  dorsal  flexion  with  abduction,  Ijecause  the  external  facet 
of  the  astragalus  allows  a  greater  range  of  motion  on  the  external 
malleolus  than  is  permitted  about  the  internal  malleolus  and 
because  the  forefoot  is  in  plantar  flexion  turned  downward  and 
inward  on  the  head  of  the  astragalas  and  in  the  reverse  direction 
in  dorsal  flexion. 

The  range   of   motion   at   the   ankle-joint   is   from  60    to   80 
degrees;  thus  dorsal  flexion  to  10  or  20  degrees  less  than    the 


Fig.  421 


Fig.  422 


Voluntary  adduction.  Voluntary  abduction. 

In  these  postures  the  foot  moves  upon  the  astragalus,  which  is  practically  fixetl  between 
the  malleoli.  Adduction,  the  turning  of  the  foot  inward  in  its  relation  to  the  leg,  is  always 
accompanied  by  elevation  of  its  inner  and  depression  of  its  outer  border.  This  is  known 
as  supination  or  inversion  of  the  foot.  The  reverse  of  this  attitude — pronation  or  eversion — 
is  an  accompaniment  of  abduction,  as  is  illustrated  in  the  figures. 

right  angle,  and  plantar  flexion  to  50  to  60  degrees  more  than  the 
right  angle  (Figs.  419  and  .420). 

Adduction  and  abduction  of  the  foot  are  carried  out  in  the 
mediotarsal  and  subastragaloid  joints. 

Adduction,  the  motion  of  turning  the  foot  inward  in  its  relation 
to  the  leg,  is  always  accompanied  by  inversion  of  the  sole  or 
supination,  and  by  plantar  flexion   which  increases  the  depth  of 


672 


ORTHOPEDIC  SUEOERY 


the  arch  because  of  the  shape  of  the  jomt  surfaces  between  the 
astragahis  and  os  calcis,  where  the  greater  part  of  the  motion 
takes  place.  Sunple  adduction  and  abduction  without  inversion 
or  eversion  is  possible  to  a  very  limited  extent  in  the  medio- 
tarsal  joint.  Its  range  may  be  tested  by  fixing  the  heel,  when 
the  forefoot  may  be  moved  slightly  from  side  to  side  upon  the 
astragalus  aiid  os  calcis.  The  range  of  motion  in  the  sub- 
astragaloid  joint  is  twice  as  free  as  in  the  mediotarsal  joint.  The 
character  of  the  motion  between  the  astragahis  and  os  calcis  is 
rotation  on  an  axis  passing  through  the  upper  and  inner  part  of 


Fig.  423 


Fig.  424 


The  direct  dorsal  flexors 
Tibialis  anterior  of  right  side;  outline  Peroneus  tertius  of  right  side;  outline 

and  attachment  areas.  (Gerrish.)  and  attachment  areas.  (Gerrish.) 


the  hea<l  of  the  astragalus,  downward  and  outward  to  the  outer 
tuberosity  of  the  os  calcis.  Thus  for  all  practical  purposes 
adduction,  inversion,  and  supination  are  synonymous  terms,  as 
are  abduction,  eversion  and  pronation. 

In  the  movement  of  adduction  the  astragalus  is  fixed  between 
the  malleoli,  and  upon  it  the  os  calcis  gli  'es  forward,  its  anterior 
extremity  turning  sligl.tly  inward;  its  inner  superior  surface  is  ele- 
vate 1,  and  its  external  surface  is  depressed.  Meanwiiile  the  fore- 
foot, attacherl  to  the  os  calcis,  is  carried  inward  and  downward 
about  the  head  of  the  astragalus;  its  inner  border  is  elevated,  and 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     673 


its  outer  border  is  depressed,  so  that  the  sole  looks  inward  and 
downward.  In  this  attitude  all  the  arches  are  increased  in  depth 
(Fig.  421). 

In  abduction  the  bones  move  upon  one  another  in  the  reverse 
direction,  the  curves  are  lessened,  and  that  of  the  inner  border  is 
obliterated   (Fig.  422). 

The  extreme  of  adduction  is  only  attained  in  the  position  of 
plantar  flexion,  because  in  this  position  the  adduction  possible  at 
the  ankle-joint  in  part,  due  to  the  contour  of  the  astragalus  and 


Fig.  425 


Fig.  426 


The  calf  muscle. 
Gastrocnemius  of  right  side;  outline  and 
attachment  areas.     (Gerrish.) 


The  plantar  flexor. 
Solcus  of  right  side;  outline  and  attach- 
ment areas.    (Gerrish.) 


in  part  to  the  greater  mobility  allowed  in  the  joint  when  the 
narrow  posterior  border  of  the  astragalus  is  alone  in  contact  with 
the  malleoli,  is  added  to  the  adduction  which  the  joints  of  the  foot 
permit. 

Extreme  abduction  is  attaine  I  in  the  attitude  of  dorsal  flexion, 
its  extent  being  about  one-half  that  of  adduction;  the  entire 
ranffe    of    motion    between    tlie    two    extremes    being   about  45 


degrees. 


4  a 


674 


ORTHOPEDIC  SURGERY 


In  this  description  the  foot  is  considered  as  moving  on  the 
leg,  but  in  the  attitude  of  rest  the  foot  becomes  the  fixed  point 
and  the  astragalus  moves  upon  the  os  calcis  in  the  manner  and  to 
the  position  already  mentioned  in  the  description  of  abduction — 
i.  e.,  it  slips  downward  and  forward  and  turns  inward;  at  the 
same  time  the  anterior  extremity  of  the  os  calcis  turns  slightly 
inward  and  dowmward,  and  its  mner  border  is  depressed.  Corre- 
sponding to  this  movement,  as  the  inner  border  of  the  foot  be- 
comes straight  or  bulges  inward,  the  navicular  is  forced  forward 
and  downward  and  the  longitudmal  arch  is  depressed.     As  has 


Ftg.  427 


Fig.  428 


The  direct  abductors. 
Percjneus  longus  of  right  side;  outline  Peroneiis  brevis  of  right  side;  outline  and 

and  attachment  areas.     (Gerrish.)  attachment  areas.     (Gerrish.) 

been  mentioned,  the  turning  of  the  leg  inward  and  the  correspond- 
ing turning  of  the  foot  outward  in  its  relation  to  it  locks  in  a 
manner  the  ankle-joint,  and  at  the  same  time  throws  the  strain 
upon  the  ligaments,  so  that  standing  in  the  erect  posture  is  possible 
with  but  little  muscular  exertion  (Fig.  434). 

To  put  it  in  a  simpler  manner,  the  leg  supporting  the  weight 
of  the  bofly  has  a  tendency  to  tilt  the  foot  over  toward  the  inner 
sile  and  to  evert  the  sole;  thus,  under  increasing  superincumbent 
weight,  the  point  of  greatest  pressure  on  the  sole  shifts  from  its 
centre  and  outer  border  toward  the  inner  border.  If,  on  the 
otlier  hand,  the  bo.ly  is  raised  upon  the  toes,  the  arch  is  relieved 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     675 


Fig.  429 


from  strain  and  the  weight  falls  upon  the  front  and  outer  part  of  the 
foot.  Plantar  flexion  and  adduction  represent,  as  contrasted  with 
the  passive  attitude  of  supporting  weight,  the  attitude  of  activity 
in  which  the  foot  is  supported  and  controlled  by  the  muscles. 

The  Function  of  the  Muscles.— The  most  important  function 
of  the  dorsal  flexors  is  to  lift  the  foot  as  it  is  swung  forward;  of 
the  plantar  flexors  to  serve  in  the  active  propul- 
sion of  the  body.  The  difference  in  function  is 
shown  by  the  relative  strength  of  the  two  groups, 
the  plantar  flexors  being  five  times  the  stronger; 
in  fact,  the  calf  muscle  (gastrocnemius  and  soleus) 
alone  is  three  times  as  strong  as  all  the  other 
muscles  of  the  foot  combined.  It  is  practically 
the  leverage  muscle,  the  others  serving  more  es- 
pecially to  fix  and  to  hold  the  forefoot  or  fulcrum 
in  its  proper  relation  to  the  leg.  It  is  also  a 
powerful  adductor  and  supinator  of  the  foot 
in  the  attitude  of  plantar  flexion  (Figs.  425  and 
426). 

The  muscles  that  more  directly  support  the 

inner  arch  of  the  foot  are  the  tibialis  posticus  and 

tibialis  anticus,  whose  tendons  approach  to  their 

attachments   in  front  of   the  astragalus.      The 

tibialis  anticus  supports  the  internal  border  of  the 

foot  from  above,  and  is  the  direct  supinator  of 

the  foot  in  dorsal  flexion — ^that  is,  if  unopposed 

it  elevates  the  inner  border  of  the  foot,  when  it 

acts  as  a  dorsiflexor.     The  tibialis  posticus  is  the 

most  powerful  adductor  (Figs.  423  and  429).   The 

extensor  longus  hallucis  is  an  adjunct  of  the  tibialis 

anticus  in  its  action  on  the  foot  as  a  whole.     The 

extensor  longus  digitorum,  including  the  peroneus 

tertius,  is  a  dorsal  flexor  and  abductor. 
Tlie  flexor  longus   hallucis,    passing    directly 

beneath  the  sustentaculum  tali,  aids  in  supporting 

the  weak  part  of  the  foot  and  its  position  demonstrates  the  im- 
portance of  the  proper  functional  use  of  the  great  toe  (Fig.  433). 
The  peroneus  longus  and  brevis  support  the  outer  arch,  and 

the  former  binds  the  foot  together  and  holds  the  great  toe  firmly 

against  the  ground;  thus  it  indirectly  supports  the  longitudinal 

arch  against  direct  pressure  (Figs.  427  arid  428).     They  also  serve 

as  abductors  and  pronators. 


The  most  impor- 
tant adductor.  Tibi- 
alis posterior  of  right 
side;  outline  and  at- 
tachment areas.  The 
most  of  the  muscle 
is  represented  as  if 
seen  through  the 
bones.     (Gerrish.) 


676  ORTHOPEDIC  SURGERY 

The  relative  strength   of  the  muscles  and   their  functions  is 
indicated  in  the  following  tables  •} 

DoRS.u.  Flexors  of  the  Foot;  Strength  Reckoned  in  Kilo- 

GRAMMETRES. 

Tibialis  anticus 0.871 

-Extensor  longus  digitorum 0.280 

Extensor  longus  pollicis 0.155 

Peroneus  tertius 0.087 

1.393 
Plantar  Flexors. 

The  calf    t  Soleus 3.256 

muscle.     \  Gastrocnemius 2.831 

Flexor  longus  poUicis 0.218 

Peroneus  longus 0.118 

Tibialis  posticus .0  094 

Flexor  longus  digitorum 0.078 

Peroneus  brevas 0.055 

6.650 

The  Foot  Considered  as  a  Mechanism.  —In  the  study  of  the 
deformities,  and  particularly  of  the  functional  weaknesses  of  the 

Fig.   430  Fig.   431 


Extensor  propriuM  hallucis  of  right  side; 
outline  and  attachment  areas.   (Gerrish.) 


Exten.sor  longus  digitorum  of  right  side; 
outline  and  attachment  areas.    (Gerrish.) 


foot,  one  must  never  lose  sight  of  the  fact  that  it  is  a  mechanism, 
subject  to  mechanical  laws,  and  that  its  deformities  and  disa- 
bilities, its  relative  strength  or  weakness,  can  be  appreciated  only 
by  comparing  it  with  the  normal  standard.     Marked  deformity  or 

'    Ucber  die  Arljeitnlei.Mtuug dor auf  die  i'lis-sgclcnko  Wirkondcu  Muskcln,  11.  Fick,  Leipzig . 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     677 


distortion  is  evident  at  a  glance,  even  though  the  apparatus  Is  not 
in  use,  but  functional  ability  can  be  judged  only  by  the  manner 
in  which  active  work  is  performed. 

As  has  been  stated,  the  foot  is,  in  activity,  a  lever,  by  means 
of  which  the  weight  of  the  body  is  lifted  and  propelled.  If  it  is 
loosely  constructerl  or  insufficiently  supported  by  the  ligaments, 
it  cannot  be  properly  controlled  by  the  muscles.  If,  on  the  other 
hand,  the  muscular  power  is  insufficient,  the  weight  of  the  body 


Fig.  432 


Fig.   433 


Flexor  longu.s  digitorum  of  right  side; 
outline  and  attachment  areas.  The  muscle 
is  represented  as  seen  from  in  front 
through  the  bones.    (Gerrish.) 


Flexor^ongus  hallucis  of  right  side; 
outline  and  attachment  areas.  The 
muscle  is  represented  as  seen  from  the 
front  through  the  bones.    (Gerrish.) 


cannot  be  lifted  and  properly  balanced  upon  it.  The  structure 
of  the  foot  may  be  normal,  and  its  muscles  may  be  of  normal 
strength,  yet  the  strain  placed  upon  it  may  be  disproportionately 
great.  The  strain  may  be  overweight  of  body,  or  the  overwork  of 
a  laborious  occupation,  but  more  often  the  machine  is  overworked 
because  it  is  weakened  by  compression  and  consequent  distortions 
and  because  it  is  subjected  to  mechanical  disadvantages  in  the 
performance  of  its  functions,  by  the  assumption  of  improper 
attitudes. 


678 


ORTHOPEDIC  SURGERY 


One  of  the  most  common  of  such  attitudes  is,  as  has  been 
mentioned,  that  of  turning  the  feet  outward  in  walking;  for  as 
the  fulcrum  is  displaced  outward,  the  strain  falls  through  the 
inner  and  weaker  side  of  the  foot.  As  a  consequence  of  the 
improper  attitude  there  is  usually,  to  a  greater  or  less  degree, 
disuse  of  the  active  leverage  function,  the  foot  being  used  some- 
what as  if  it  were  a  movable  pedestal.     (Fig.  418).      This  posture 


Fig.  434 


Fig.   435 


An  attitude  that  simulates  the  flat-foot. 
(See  Fig.  43.5.) 


Fig.  435  compared  with  Fig.  443 
illustrates  the  voluntary  protection  of 
the  foot  from  overstrain. 


often  induces  or  is  associated  with  abduction  of  the  foot,  the  passive 
attitude  that  predisposes  to  pain  and  weakness. 

This  disuse  of  the  active  function  may  be  unnecessary,  just  as 
the  outward  rotation  of  the  feet  with  which  it  is  associated  is  a 
habit,  a  habit  that  is  often  the  result  of  improper  teaching.  On 
the  other  hand,  the  haljitual  assumption  of  the  passive  attitude 
may  be  induced  by  injury  or  disease  of  the  foot,  or  by  corns  or 
Ijunions,  or  by  improper  shoes.  For  under  such  conditions  the 
strain  of  the  leverage  function  increases  the  discomfort;  conse- 
quently it  is  discontinued.     It  must  not  be  inferred  that  such 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     679 

improper  attitudes  lead  directly  to  weakness  and  discomfort, 
for  in  most  instances  an  ungraceful  carriage  and  gait  are  the  only 
ill  effects.  The  improper  attitudes  must,  however,  lessen  the 
power  and  resistance  of  the  foot,  and  they  must  be  reckoned, 
therefore,  among  the  impoi'tant  predisposing  causes  of  disability. 
The  passive  attitude,  it  will  be  remembered,  is  the  attitude 
of  rest,  in  which  the  ligaments  bear  the  greater  part  of  the  strain 
and  in  which  the  arches  of  the  foot  are  depressed  or  obliterated. 

The  Weak  Foot. 

Synonjnns.  — Splay-foot,  flat-foot. 

The  introductory  pages  lead  naturally  to  the  consiJeration  of 
the  most  important  of  the  acquired  disabilities  of  the  foot,  a 
disability  whose  most  important 
characteristic  in  the  mildest  and 
in  the  most  advanced  type  is  the 
^persistence  of  the  passive  attitude 
of  abduction,  or  an  approxima- 
tion to  it,  in  place  of  normal 
alternation  of  posture.  Disuse 
of  function  is  followed  by  restric- 
tion of  motion,  particularly  in  the 
range  of  adduction  and  plantar 
flexion,  and  finally  by  persistent 
deformity,  a  deformity  which  is 
simply  an    exaggeration  of  the 

normal    posture    assumed    when  Tyisical  "flat-fouL"  of    moaerate    degree, 

,,        p  •    1   .      /TT  illustrating  the  component  elements  of  ab- 

the    loot   supports     weight     {big.        dviction  and  depression  of  the  arch. 

434).  This  is  the  so-called  flat- 
foot  (Fig.  436).  At  first  glance  it  may  seem  that  the  depression  of 
the  arch  is  the  most  noticeable  peculiarity  in  a  characteristic  case  of 
flat-foot,  and  that  the  popular  name  is,  therefore,  an  appropriate 
one.  On  closer  examination,  however,  it  will  appear  that  the  foot 
is  not  flat  because  its  "  keystone  has  sunk,"  but  that  the  lowered 
arch  is  caused  by  lateral  displacement  (abduction) .  This  fact  may 
be  demonstrated  by  adducting  the  foot  sufiiciently  to  restore  ap- 
proximately the  normal  relation  between  it  and  the  leg,  a  movement 
which  will  restore  its  normal  contour. 

The  deformity  then  may  be  analyzed  as  follows: 
1.    The  leg  is  displaced  inward,  so  that  the  weight  falls  upon 
the  inner  side  of  the  foot.    2.  The  leg  is  rotated  inward   so 
that  a  line  drawn  through  its  centre,  prolonged  from  the  crest 


680 


OR THOPEDIC  S UB GER Y 


of  the  tibia,  instead  of  falling  over  the  second  toe,  now  points 
inside  the  great  toe,  or  even  over  the  centre  of  the  mternal  border 
of  the  foot  (Figs.  436  and  439). 

It  has  been  stated  that  under  normal  conditions,  in  the  act  of 
passive  weight  bearing,  the  astragalus  rotates  downward  and 
inward  upon  the  os  calcis,  depressing  its  anterior  and  internal 
border  until  the  movement  is  checked  by  the  strong  ligaments 
connecting  the  bones,  the  calcaneonavicular,  the  deltoid,  and  the 
interosseus;  in  other  words,  in  the  passive  attitude  the  leg  has  a 
tendency  to  slip  do^Aiiward  and  inward  from  off  the  foot.  In  the 
weak  foot  this  mclination  has  become  an  accomplished  fact,  for  the 
normal  movement  has  become  so  exaggerated  by  the  distention  of 
the  ligaments  and  by  the  weakness  of.  the  supportmg  muscles  that 
an  actual  subluxation  is  present.  The  astragalus  has  rotated  and 
slipped  far  to  the  inner  side  of  its  normal  position,  to  an  attitude 


Fig.  437 


Fig.  438 


The  relation  of  the  astragalus  to  the 
OS  calcis. 


The  relation  of  the  astragalus  and  os 
calcis  in  flat-foot. 


of  exaggerated  rotation  and  plantar  flexion,  so  that  its  head  can 
be  plainly  felt  on  the  internal  border  of  the  foot.  The  anterior 
extremity  of  the  os  calcis  is  depressed  and  is  turned  slightly  in- 
ward and  its  internal  border  is  lowered  (Fig.  438). 

The  navicular  bone  has  been  depressed  with  the  head  of  the 
astragalus,  although  to  a  less  degree,  it  has  been  forced  farther 
away  from  the  os  calcis,  and  the  entire  inner  border  of  the  foot 
is  lowered.  Thus  the  depression  of  the  arch  is  always  accom- 
panied and  preceded  })y  a  bulging  inward  of  the  inner  side  of  the 
foot. 

Tlie  typical  flat-foot  is,  as  it  were,  broken  in  the  centre  (Fig. 
436),  the  posterior  division  having  turned  inward  and  downward, 
while  the  forefoot  is  forced  downward  and  outward.  The  dislo- 
cation may  be  so  extreme  that  the  entire  sole  of  the  foot  rests 
upon  the  ground,  and  a  callus  even  may  be  found  at  the  point 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT 


681 


that  usually  represents  the  highest  point  of  the  arch,  which  now 
supports  the  greatest  burden. 

In  this  change  of  relation  between  the  bones  the  arched  part 
of  the  foot  or  waist  appears  much  broader  than  normal,  even 
broader  than  the  front  of  the  foot;  the  heel  projects,  the  external 
malleolus  is  depressed  and  carried  forward  by  the  rotation  of 
the  leg,  and  is  much  less  prominent  than  normal;  the  internal 


Fio.   439 


Fig.   440 


1 

^^^H    JI^Kii^ 

Weak  feet,  arches  not  depresseil. 


Weak  feet,  showing  the  inward  rotation 
of  the  legs  when  the  abducted  feet  are 
placed  side  by  side,  indicating  an  attitude 
of  persistent  abduction. 

malleolus  is  more  prominent,  and  with  the  astragalus  it  overhangs 
the  bearing  surface  of  the  sole.  The  entire  mechanism  is  out  of 
gear;  its  motion  is,  therefore,  very  much  restricted.  It  is  mani- 
festly impossilde  for  the  patient  to  adduct  the  forefoot — that 
is,  to  turn  it  inward  about  the  head  of  the  tlisplaced  astragalus. 
Plantar  flexion  is  also  much  limited,  because  of  the  persistent 
adduction  and  plantar  flexion  of  the  astragalus.  Dorsal  flexion, 
on  the  other  hand,  although  it  is  actually  restricted,  may  appear  to 


682  ORTHOPEDIC  SURGERY 

be  abnormally  free,  because  the  forefoot  is  abducted  and  slightly 
dorsiflexed  upon  the  head  of  the  astragalus  (Fig.  436). 

The  disability  and  its  accompanying  deformity  are  found  in 
eTery  grade  of  severity.  Discomfort  usually  begins  when  the  strain 
upon  the  muscles  is  disproportionate  to  their  strength,  and  it 
is  increased  when  the  ligaments  begin  to  give  way  under  strain, 
allowing  the  bones  to  occupy  an  abnormal  relation  to  one  another. 
It  is  evident,  therefore,  that  the  individual  in  whose  foot  the  arch 
is  well-formed  and  whose  ligaments  are  firm,  will  suffer  from  the 
symptoms  of  strain  long  before  the  arch  has  been  depressed; 
also,  that  the  lateral  mward  bulgmg,  characteristic  of  abduction, 
must  be  very  great  before  the  arch  is  completely  flattened.  In 
this  t^-pe  the  prominent  deformity  is  lateral  displacement  (valgus). 
On  the  other  hand,  if  the  individual  has  mherited  a  low  arch, 
or  if,  as  the  result  of  weakness  in  early  life,  the  arch  has  been 
depressed  or  has  never  formed,  accommodative  changes  in  the 
bones  will  have  taken  place  during  growth,  so  that  the  flat-foot 
of  this  type  will  not  be  attended  with  as  much  change  in  its  rela- 
tion to  the  leg,  and,  therefore,  disturbance  of  function,  as  in  the 
typical  case  that  has  been  described.  This  latter  class  of  cases 
exemplifies  the  popular  type  of  flat-foot  that  may  exist  without 
pain  or  disability,  and  in  which  the  most  noticeable  peculiarity  is 
the  obliteration  of  the  arch  (planus).    (Contrast  Figs.  440  and  442.) 

In  certain  instances  abnormal  laxity  of  ligaments  allows  de- 
formity of  the  valgus  type  when  weight  is  borne,  yet  the  foot, 
controlled  by  efficient  muscles,  may  be  apparently  normal  in  func- 
tional ability,  while  in  other  cases  in  which  the  ligaments  are  nor- 
mal and  yet  are  subjected  by  insufficient  muscular  protection  to 
overstrain,  disability  and  pain  may  precede  noticeable  deformity. 

It  is  evident  that  the  lowering  of  the  arch  is  of  secondary  im- 
portance in  the  deformity,  and  that  the  popular  significance  of 
painful  flat-foot,  as  an  inherited  and  irremediable  wealaiess,  is 
most  misleading.  Yet  it  seems  to  have  governed  the  treatment 
of  the  disability  until  very  recently.  On  the  one  hand,  the  early 
cases  were  overlooked  because  the  foot  was  not  flat,  while  those 
in  which  the  deformity  was  more  advanced  were  either  neglected 
or  were  treated  by  simple  supports  beneath  the  arch  or  by  opera- 
tion without  regard  to  the  loss  of  function,  and,  therefore,  without 
hope  of  ultimate  cure. 

As  has  been  stated,  there  is  one  feature  common  to  every  grade 
of  the  so-called  flat-foot:  the  foot  regarded  as  a  machine  is  weak 
as  compared  to  the  normal  standard — weak  because  of  the  per- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     683 

sistence  of  the  attitude  of  rest  and  relaxation,  as  contrasted  with 
that  of  activity  and  strength,  and  weak  because  the  proper  rela- 
tion between  the  power  and  the  fulcrum  is  changed.  Even 
the  inherited  flat-foot  or  the  flat-foot  which  has  never  caused 
symptoms  is  weak  in  the  sense  that,  in  use,  it  lacks  the  spring 
and  elasticity  characteristic  of  the  perfect  machine.  The  term 
weak  foot  may  be  used,  then,  to  include  all  types  of  the  disability. 

In  one  weak  foot  the  arch  has  disappeared  (Fig.  436);  in 
another  weak  foot  the  arch  is  of  normal  depth,  but  the  foot  is 
habitually  abducted  (Fig.  440).  In  one  case  the  deformity 
appears  only  under  weight;  in  another  the  foot  is  held  rigidly 
in  the  deformed  position  by  muscular  spasm.  In  one  instance 
there  may  be  great  deformity  without  pain;  and  in  another  dis- 
abling weakness  and  pain  without  noticeable  deformity.  In  one 
case  the  foot  is  unable  to  perform  its  functions  because  of  its 
inherent  weakness;  in  another  the  disability  may  be  due  simply 
to  the  improper  use  of  a  normal  structure. 

Pathology. — Supposing  the  foot  to  have  been  normal  before  it 
began  to  break  down,  it  is  evident  that  persistent  deformity  could 
not  have  been  acquired  without  marked  changes  m  its  internal 
structure.  In  a  general  way  these  changes  have  been  indicated 
already.  The  ligaments  on  the  internal  aspect  of  the  foot  and  of 
the  ankle-joint  are  weak  and  distended;  the  unused  portions  of  the 
articular  surfaces  of  the  joints  may  be  denuded  of  cartilage,  while 
new  facets  may  have  formed  to  accommodate  the  changed  rela- 
tions of  the  bones.  For  example,  the  external  malleolus  may  be 
in  direct  contact  with  the  os  calcis;  evidences  of  injury  and  of 
abnormal  pressure  may  be  found  in  the  thickened  periosteum, 
in  formation  of  osteophytes,  while  the  internal  structure  of  the 
bones  has  been  changed  in  adaptation  to  the  new  conditions.  The 
disused  muscles,  particularly  the  plantar  flexors  and  adductors, 
have  become  atrophied,  as  evidenced  by  the  shrunken  calf.  The 
muscles  on  the  inner  border  of  the  foot  have  been  overstretched, 
while  those  on  the  upper  and  outer  part  have  become  shortened 
and  contracted  in  accommodation  to  the  habitual  posture.  Such 
a  foot  represents  an  extreme,  it  may  be  an  irreme:liable  degree 
of  deformity;  but  in  by  far  the  greater  proportion  of  the  cases 
the  pathological  changes  have  not  advanced  to  a  stage  that 
precludes  successful  treatment. 

Etiology. — In  all  cases  the  actual  symptoms  of  pain  and  dis- 
ability are  due  to  a  disproportion  between  the  burden  or  strain 
and  the  ability  of  the  machine  to  perform  it. 


684  ORTHOPEDIC  SURGERY 

This  theoiy  accounts  for  the  fact  that  the  weak  foot,  although 
very  common  in  childhood,  does  not,  as  a  rule,  cause  troublesome 
symptoms  until  adolescence,  when  the  weight  and  strain  put  upon 
it  are  increased.  It  explains  why  the  foot,  which  may  be  fairly 
normal  in  structure,  breaks  down  often  in  later  adolescence  or 
early  adult  life  when  the  continuous  strain  of  regular  occupation 
is  undertaken.  It  is  evident,  also,  that  an  occupation  that  in- 
duces a  persistence  of  the  passive  attitude,  that  of  waiters,  cooks, 
and  bartenders,  for  example,  exposes  the  feet  to  greater  strain 
than  one  which  encourages  alternation  of  postures.  And  that 
the  symptoms  are  likely  to  be  more  severe  and  the  deformity  to 
be  greater  among  those  who  are  obliged  to  labor  than  among 
those  who  are  not.  Overwork  or  strain,  of  occupation  or  other- 
wise, may  be  temporarily  disproportionate  because  of  general 
weakness,  as,  for  example,  during  pregnancy  or  after  recovery 
from  exliausting  disease;  or  because  of  local  injury  or  disease  of 
the  foot  itself,  which  weakens  it  directly  or  indirectly  by  inducing 
improper  attitudes.  This  theory  explains  why  there  is  no  con- 
stant relation  between  the  degree  of  deformity  and  the  severity  of 
the  symptoms,  for,  although  all  weak  feet  are  mechanically  weak, 
yet  all  weak  feet  are  not  necessarily  painful  feet.  Pain  is  not 
caused  because  the  foot  is  flat;  it  is  a  symptom  of  strain  and 
injury  and  of  progressive  deformity.  The  progress  of  the  de- 
formity may  be  temporarily  or  permanently  checked  at  any  stage, 
either  by  removal  of  the  exciting  causes  or  because  of  the  resist- 
ance of  the  tissues;  then  the  pain  intermits  or  ceases. 

This  conception  of  the  foot  as  a  mechanism,  of  which  grades 
of  efficiency  may  be  recognized,  has  a  great  advantage,  since  it 
enables  one  to  perceive  wherein  a  foot  is  weak,  even  though  the 
weakness  causes  no  symptoms  whatever,  and  thus  to  prevent 
discomfort  and  deformity  l^y  the  recognition  and  treatment  of  ito 
predisposing  causes. 

Statistics. — A  brief  analysis  of  1000  cases  of  so-called  flat-foot 
treated  at  the  Hospital  for  Ruptured  and  Crippled  will  represent 
fairly  the  points  of  general  interest  in  this  class  of  cases: 

The  Agr  and  Srx  of  the  Patients. 

Age.  Males.  Females.      Total. 

Ten  ycarH  or  less 68  30               98 

Ten  to  fifteen 112  87  199 

Fifteen  to  twenty 144  83  227 

Twenty  to  twenty-five 94  53  147 

Twenty-five  to  thirty 68  41  109 

More  than  tliirty 132  88  220 

618  382  1000 

Foot  affected:  right,  133;  left,  138;  both,  729. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     685 

In  58  cases  the  cause  of  the  disabihty  appeared  to  be  injury, 
and  in  65  instances  it  was,  apparently,  due  to  rheumatism  or  to 
rheumatoid  arthritis.  The  symptoms  usually  appear  first  in  one 
foot,  and,  as  a  rule,  they  are  at  all  times  more  marked  on  one 
side.  Of  569  instances,  in  which  the  duration  of  symptoms  was 
recorded,  it  was  six  months  or  less  in  409. 

The  age  of  the  patients  is  of  interest  as  bearing  on  the  question 
of  prognosis :  426  were  between  ten  and  twenty  years  of  age,  and 
780  were  less  than  thirty. 

Hospital  statistics  cannot  adequately  represent  the  subject,  for, 
as  a  rule,  it  is  because  of  disability  and  pain  that  these  patients 
apply  for  treatment.  In  the  larger  proportion  of  the  cases  recorded 
muscular  spasm  and  rigidity  were  present,  in  234  instances  to 
such  a  degree  that  forcible  overcorrection  was  advised — an  opera- 
tion rarely  necessary  in  private  practice. 

It  is  in  childhood  that  the  prevention  of  subsequent  weakness 
and  deformity  is  of  the  first  importance,  yet  but  98  children  of 
ten  years  of  age  or  less  are  recorded,  and  many  of  these  were 
brought,  not  for  weakness  or  deformity,  but  for  treatment  of  the 
symptomatic  in-toeing. 

Sjnnptoms. — As  has  been  stated,  the  symptoms  of  the  weak 
foot,  although  similar  in  type,  vary  in  severity  according  to  the 
local  con:'ition  and  the  disturbance  of  function,  the  work  to  be 
performed,  and  the  susceptibility  of  the  individual.  The  earliest 
symptom  is  usually  a  sensation  of  weakness;  the  patient  begins 
to  recognize  as  familiar  a  feeling  of  discomfort,  of  tire  and  strain 
about  the  inner  side  of  the  foot  and  ankle;  sometimes  after  long 
standing  a  dull  ache  in  the  calf  of  the  leg  or  pain  at  the  knee, 
hip,  or  in  the  lumbar  region,  symptoms  more  common  in  women 
than  in  men;  or  after  overexertion  a  momentary  sharp  pain  radi- 
ating from  the  point  of  weakness;  thus  the  patient  often  dates  the 
history  of  his  trouble  from  a  long  walk  or  other  form  of  over- 
work. After  a  time  the  patient  may  become  aware  that  he  is  accom- 
modating his  habits  to  his  feet;  he  rides  when  he  once  walked;  he 
sits  when  he  once  stood;  he  no  longer  runs  up  or  down  stairs  or 
springs  off  the  street-car.  His  feet  have  lost  their  spring,  as  he 
expresses  it,  which  means  that  the  foot  is  no  longer  supported  and 
controlled  by  muscular  activity  and  is  no  longer  used  as  a  lever. 
Not  infrequently  early  symptoms  are  pain  and  sensitiveness  at  the 
centre  of  the  heel,  explained  in  part  by  the  jarrmg  heel  walk  which 
is  always  assumed  when  the  foot  is  weak,  and  in  part  by  the  strain 
upon  the  attachments  of  the  deep  plantar  ligaments.     The  patient 


686  ORTHOPEDIC  SURGERY 

may  complain  that  lie  camiot  buy  comfortable  shoes;  the  reason 
is  that  the  "weak  foot  under  use  is  changed  in  shape,  so  that  the 
shoe  that  was  comfortable  in  the  mornmg  compresses  the  foot 
painfully  at  night;  thus  increasing  discomfort  from  corns,  bunions, 
enlarged  great  toe-joints,  and  deformities  of  the  toes  is  experienced. 
Coldness  and  numbness,  congestion  and  increased  perspiration, 
caused  by  the  impaired  circulation  and  weakness,  are  common 
symptoms  in  this  class  of  cases.  Actual  pain  is,  as  a  rule,  felt 
only  when  the  foot  is  in  use;  it  ceases  under  temporary  rest  or 
relief  from  disproportionate  work,  and  it  is  this  remittance  of 
symptoms,  together  with  the  fact  that  the  discomfort  is  usually 
more  marked  in  damp  weather,  that  leads  so  often  to  the  mistaken 
diagnosis  of  rheumatism.  The  foot  is  weak  and  vulnerable;  the 
patient  now  recognizes  that  he  has  what  he  speaks  of  as  a 
weak  ankle,  or  sprain,  or  gout,  or  rheumatism,  but  if  he  has 
accommodated  himself  to  the  weakness  but  little  discomfort  is 
experienced.  In  many  instances  such  relief  or  accommodation  is 
impossible,  and  it  is,  therefore,  among  the  workmg  class  that  one 
oftener  sees  the  frank  and  rapid  development  of  the  disability 
and  deformity.  The  range  of  motion  becomes  more  and  more 
restricted;  the  habitual  attitude,  at  first  exaggerated  to  deformity 
only  under  the  influence  of  the  weight  of  the  body,  remains  as  a 
permanent  displacement  of  the  bones.  The  weak  and  dislocated 
foot  is  subjected  to  constant  injury,  to  what  may  be  likened  to  a 
succession  of  slight  sprains,  so  that  local  congestion,  sensitiveness, 
and  swelling  may  appear,  together  with  muscular  spasm,  rigidity, 
and  pain  on  passive  motion.  Because  of  this  stiffness  of  the  foot, 
which  has  lost  the  power  to  accommodate  itseK  to  inequalities  of 
the  surface,  the  patient  dreads  to  cross  a  rough  pavement,  for 
every  misstep  is  a  source  of  pain.  Another  symptom,  the  dis- 
comfort felt  in  changing  from  a  position  of  rest  to  activity,  which 
is  usually  present  in  slight  degree  at  every  Stage,  now  becomes 
more  prominent.  The  patient,  after  sitting  or  on  rising  in  the 
morning,  is  unable  to  walk,  but  staggers  or  limps  for  several 
minutes,  a  symptom  explained  by  the  fact  that  when  the  foot  is 
at  rest  there  is  a  partial  reposition  of  the  displaced  bones,  which 
must  again  be  forced  into  the  deformed  posture  that  has  become 
habitual.  The  local  sensitiveness  and  muscular  spasm  are  increased 
by  use,  so  that  the  {patient  may  have  difficulty  in  removing  the 
shoe  at  night,  and  the  symptoms  relieved  l)y  the  rest  of  Sunday 
become  j)rogressively  worse  during  the  week.  The  pain  and 
discomfort  are  more  general  in  ciiaracter,  and  are  often  referred 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     687 

to  the  dorsum  of  the  foot,  representing  muscular  rigidity  and 
tension,  and  to  the  ankle  where  the  external  malleolus  is  grinding 
out  a  facet  in  the  projecting  os  calcis.  The  patient  may  now 
complain  of  discomfort  in  the  feet  and  cramps  in  the  legs,  even 
when  in  bed,  and  the  weakness,  awkwardness,  and  even  mental 
depression  may  be  so  noticeable  that  the  case  is  sometimes 
mistaken  for  serious  disease  of  the  nervous  system. 

The  appearance  of  such  a  foot  has  already  been  describe.!,  and 
the  effect  of  the  deformity  on  its  functions  should  be  evident. 
The  gait  is  slouchy  and  cloddy,  what  has  been  spoken  of  as  the 
pedestal  walk;  the  feet  are  simply  pushed  by  one  another,  in 
the  attitude  of  eversion,  the  knees  are  slightly  flexed,  and  the 
weight  is  borne  entirely  upon  the  posterior  segment  of  the  foot. 
The  muscles  have  atrophied,  the  foot  is  cold  and  congested  from 
its  continued  inactivity,  and  it  is  usually  bathed  in  perspiration. 
A  certain  range  of  motion  remains  at  the  ankle-joint,  but  adduc- 
tion is  absolutely  restricted  by  the  shortened  and  spasmodically 
contracted  muscles  on  the  outer  and  upper  surface.  This  type 
represents,  of  course,  only  the  severe  variety  that  is  more  likely 
to  be  seen  in  hospital  than  in  private  practice;  and  it  would  seem, 
were  it  not  for  the  evidence  to  the  contrary  which  the  histories 
of  the  patients  present,  that  the  nature  of  the  trouble  must  be 
recognized  at  a  glance.  But  in  the  milder  and  earlier  cases  the 
diagnosis  is  not  always  so  easily  made. 

Diagnosis. — In  all  cases  of  suspected  weakness  of  the  foot  a 
thorough  and  orderly  examination  should  be  made,  not  only  of 
its  appearance,  but  also  of  its  functional  ability.  Such  an  exami- 
nation is  not  merely  for  the  purpose  of  diagnosis,  which  is  usually 
apparent,  but  in  order  that  the  degree  and  character  of  the 
temporary  or  permanent  changes  in  structure  and  function  may 
be  properly  estiraatetl. 

Attitudes. — One  begins  the  examination  by  notmg  the  manner 
of  standing  and  walking.  The  heel  walk,  the  exaggerated  turning 
out  of  the  feet,  the  slouchy  gait  in  which  the  leg  is  never  com- 
pletely extended,  in  which  the  power  of  the  calf  muscle  is  not 
applied,  and  in  which  the  essential  postures  of  the  foot  are  disused, 
are  all  elements  of  weakness  tliat  should  be  corrected  whether 
they  cause  symptoms  or  not. 

Distribution  of  Weight  and  Strain. — Tlie  distribution  of  the 
weight  of  the  body  and  the  habitual  use  of  the  foot  are  often 
made  evident  by  examining  the  worn  shoe.  If  it  is  bulged  inward 
at  the  arch  or  worn  away  on  the  inner  side  of  the  sole  it  shows 


688 


ORTHOPEDIC  SUBGEBT 


weakness  (Fig.  445).  The  same  observations  are  then  made  on 
the  bare  feet,  particular  attention  being  paid  to  the  Hne  of  strain 
or  leverage;  thus  a  line  drawn  down  the  crest  of  the  tibia  from 
the  centre  of  the  patella,  continued  over  the  foot,  should  meet  the 
interval  between  the  second  and  third  toes;  if  it  falls  over  or 
inside  the  great  toe,  it  shows  that  the  foot  is  working  at  a  dis- 
advantage (Fig.  439). 

Contour. — ^The  contour  of  the  foot  should  then  be  examined; 
its  internal  border  should  curve  slightly  outward,  so  that  if  the 

Fig.  441 


The  ordinary  typo  of  weak  fnut  in  a  fliild.     'I'he  attitude  of  abduction  causes  the 
apparent  flat-foot.     (See  Fig.  442.) 

feet  are  placed  side  by  sitle  with  the  toes  and  heels  in  apposition 
a  slight  interval  remains  between  them;  if  this  slight  concavity  is 
replaced  by  a  noticeable  convexity  when  weight  is  borne  the  foot 
is  weak  (Fig.  440).  ''i'liis  change  in  contour  is  the  earliest  and 
sometimes  the  only  evidence  of  deformity.  The  arch  of  the 
foot  properly  protecterl  by  the  muscles  and  by  a  proper  attitude, 
sinks  but  little  under  weight;  there  is  a  slight  elasticity  only, 
as  the  strain  is  thrown  more  to  the  inner  side  of  the  median  line, 
and  if  the  deoression  is  marked  it  shows  weakness. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     689 

Bearing  Surface. — ^The  exact  amount  of  bearing  surface  may  be 
shown  by  an  imprint  upon  carbon  paper  or  by  smearing  the  sole 
with  vaseline;  then,  as  tlie  patient  stands  upon  a  sheet  of  white 
paper,  the  outh'ne  of  the  foot  should  be  traced  so  that  the  relative 
size  of  the  imprint  to  that  of  the  foot  may  be  shown  and  compared 
with  the  normal  standard  (Fig.  447). 

Or  the  patient  may  stand  upon  a  square  of  plate  glass  fixed  in 
a  table  and  the  bearing  surface  may  be  examined  under  different 

Fig.    442 


Voluntary  correction    of   the  dcforniity,  illiist rating  parlicularly   the  restoration  of  the 
arch.     (See  Fig.  441.) 

degrees  of  pressure  and   in  difl'erent  attitudes  as  suggested  by 
Lovett. 

The  Range  of  Motion. — Tlie  balance  of  the  foot,  as  shown  by 
the  range  of  motion,  is  next  to  l)e  tested,  for  its  limitation  is  one 
of  the  earliest  signs  of  improper  attitudes  and  of  weakness.  This 
range  of  motion  varies  somewhat  within  normal  limits;  it  is  usually 
greater  in  childhood  than  in  adult  life,  greater  in  the  slender 
than  in  the  massive  foot,  and  greater  in  the  foot  used  properly 
than  in  one  that  is  not.  The  first  test  is  applied  to  simple  dorsal 
and  plantar  flexion;  the  leg  must  be  fully  extended  at  the  knee; 

44 


690  ORTHOPEDIC  SUBGEBT 

the  line  of  strain  must  be  in  its  normal  relation,  so  that  the  foot 
may  be  neitlier  addiicted  nor  abducted,  and  the  observation  must 
be  made  on  its  outer  border. 

In  this  position  the  patient  shouLl  be  able  to  flex  the  foot  from 
10  to  20  degrees  less  than  the  right  angle,  and  to  extend  it  from 
40  to  50  degrees  beyond  the  right  angle,  the  range  of  motion 
being  from  50  to  60  degrees  (Figs.  419  and  420). 

By  far  the  most  important  test  is  that  of  the  power  of  adduc- 
tion or  inversion  of  the  foot,  the  test  of  the  mediotarsal  and  sub- 
astragaloid  joints,  a  motion  in  which  the  os  calcis  is  drawn  for- 
ward and  mward  under  the  astragalus,  while  the  forefoot  is  flexed 
about  its  head.  With  the  leg  extended  and  the  patella  in  the  median 
line  the  foot  is  turned  inward  as  far  as  possible;  the  elevation 
of  its  inner  border  or  supination  and  the  turning  in  of  the  heel 
are  well  illustrated  in  Fig.  421;  the  actual  range  of  adduction 
is  somewhat  difficult  to  measure,  but  it  is  about  30  degrees. 
Even  the  mild  and  early  cases  of  weak  foot  usually  show  some 
limitation  of  this  most  important  motion,  and  in  many  instances 
it  is  completely  lost,  the  patient  turning  the  entire  limb  in  the  effort 
to  adduct  the  foot.  The  less  important  motion  of  abduction 
may  be  tested  also  (Fig.  422) ;  its  range  is  about  half  that  of  adduc- 
tion, so,  also,  the  range  of  supination  or  inversion  of  the  sole 
is  nearly  twice  as  great  as  that  of  pronation  or  eversion  of  the 
sole.  In  other  words,  the  internal  border  of  the  foot  can  be  raised 
twice  as  far  from  the  floor  as  can  the  external  border.  The  range 
of  passive  motion  is  then  tested  by  pushing  the  foot  in  all  directions. 
The  range  of  dorsal  flexion  is  from  five  to  ten  degrees  beyond  that 
of  voluntary  motion,  while  passive  extension,  so  far  as  it  applies 
to  the  ankle-joint,  is  about  the  same  as  the  voluntary,  although 
the  forefoot  may  be  still  farther  bent  downward  at  the  mediotarsal 
joint.  The  limit  of  passive  adduction  is  considerably  beyond 
that  of  voluntary  inversion.^ 

Passive  motion  serves  several  purposes;  contrasted  with  the 
range  of  voluntary  motion  it  shows  the  habitual  use  of  the  foot, 
since  the  motion  least  used  is  most  limited.  It  also  makes  evi- 
dent the  slight  restriction  of  motion  and  the  presence  of  local  sensi- 
tiveness, which,  even  in  early  cases,  are  usually  present.     Thus, 

1  As  adduction  and  inversion  and  abduction  and  eversion  are  always  combined,  one 
term  is  used  to  signify  the  movement  inward  or  outward;  thus,  inversion  means  adduction; 
abduction  implies  eversion.  A  fixed  attitude  of  adduction  and  inversion  is  called  varus;  a 
fixed  attitude  of  abduction  and  eversion  is  called  valgus.  Varus  and  valgus  signify,  there- 
fore, deformity.  Thus  the  term  valgus,  although  it  may  be  properly  applied  to  designate 
the  deformity  of  weak  foot,  is  usually  reserved  for  the  more  extreme  and  persistent 
distortion  of  talipes. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     691 

if  pressure  is  made  just  in  front  of  and  below  the  internal  malle- 
olus, at  the  astragalonavicular  junction,  and  if  at  the  same  time 
the  foot  is  forcibly  adducted,  the  patient  will  complain  of  pain 
at  the  point  of  pressure  and  of  a  feeling  of  constriction  and 
tension  about  the  dorsum  of  the  foot  before  the  normal  limit  of 
motion  is  reached.  \Vlien  the  foot  is  dorsiflexed  the  plantar 
fascia  is  put  upon  the  stretch,  and  its  condition  may  be  noted, 
for  a  contracted  and  sensitive  plantar  fascia  may  cause  sufficient 
discomfort  to  induce  improper  attitudes  and  thus  it  may  predispose 
to  further  disability. 

Varieties. — ^This  mode  of  examination  will  demonstrate  the 
disability,  and  the  secondary  changes  in  the  mechanism,  which 
must  be  overcome  before  a  cure  can  be  accomplished.  By  it  one 
will  learn  to  recognize  several  grades  of  weak  foot: 

1.  The  normal  foot  improperly  used,  as  shown  by  the  manner 
of  standing  and  walking  (Fig.  418). 

2.  The  foot  which  because  of  laxity  of  ligaments  or  insufficient 
muscular  support  is  forced  by  the  weight  of  the  body  into  an 
attitude  of  deformity;  that  is,  in  which  the  foot  under  weight 
falls  into  an  abnormal  attitude  of  abduction  in  its  relation  to  the 
leg  as  evidence  I  by  the  inward  projection  of  its  inner  border  and 
by  the  overhanging  internal  malleolus.  As  a  rule,  there  is  sufficient 
laxity  of  ligaments  to  allow  a  depression  of  the  arch,  as  shown  by 
the  imprint,  but  in  other  instances,  although  the  arch  seems  lower 
because  of  the  characteristic  attitude  of  abduction,  in  which  the 
leg,  as  it  were,  overhangs  the  foot,  yet  the  imprint  sliows  that 
there  is  no  increase  in  the  area  of  bearing  surface.  Indeed,  if 
the  eversion  is  sufficient  to  raise  the  outer  border  of  tlie  foot,  this 
may  be  even  smaller  than  normal;  thus,  an  individual  may  suffer 
from  so-called  flat-foot  whose  arch  is  actually  exaggerated  (Fig. 
440). 

3.  The  weak  foot,  which  shows  typical  deformity  under  use 
and  in  which  the  range  of  voluntary  motion  is  somewhat  limited, 
particularly  in  the  direction  of  plantar  flexion  and  adduction. 
Forced  motion  causes  discomfort  and  pain,  indicating  certain 
accommodative  changes  in  structure,  which  are  not  apparent 
when  the  foot  is  not  in  use  (Fig.  436). 

4.  The  foot  which  presents  typical  and  persistent  deformitv, 
whether  it  is  m  use  or  not,  and  in  which  the  range  of  both  volun- 
tary and  passive  motion  is  much  restricted.  In  all  of  these  varieties 
the  improper  functional  use  of  the  foot,  particularly  tiie  loss  of 
active  leverage,  is  very  evident  when  the  patient  walks  (Fig.  445). 


692  ORTHOPEDIC  SUBOEBT 

Limitation  of  Motion  and  Muscular  Spasm. — Limitation  of  motion 
is  caused  by  the  changes  in  structure  m  accommodation  to 
functional  use.  These  are  first  evident  in  the  muscles  and  liga- 
ments, and,  finally,  in  the  articular  surfaces  of  the  bones.  Added 
to  this  underlymg  limitation  of  motion  there  is  usually  a  certain 
degree  of  muscular  spasm,  which  varies  in  grade  with  the  local 
congestion,  irritation,  and  inflammation  of  the  joints  and  tissues. 
In  the  quiescent  flat-foot  it  may  be  absent,  but  on  renewed  injury 
or  overwork  of  the  weak  structure  it  again  appears.  It  depends 
also  upon  the  irritable  condition  of  the  overworked  and  contracted 
abductor  muscles,  practically  the  only  group  which  retains  func- 
tional power;  thus  the  spasm,  as  has  been  stated  in  describing 
the  severe  and  painful  type  of  weak  foot,  is  greater  after  the  day's 
use  and  relaxes  somewhat  during  the  night.  The  degree  of 
muscular  spasm  and  rigidity  corresponds  with  the  intensity  of  the 
symptoms,  but  by  no  means  with  the  depression  of  the  arch  or 
with  the  duration  of  the  deformity. 

Extreme  Tjrpes  of  Weak  Foot.  1.  Persistent  Abduction. — In 
one  type  of  deformity  the  foot  is  twisted  outward  and  upward. 
It  may  be  everted  to  such  an  extent  that  practically  the  weight 
is  borne  upon  the  heel  and  the  ball  of  the  great  toe.  In  such 
instances  the  astragalus,  although  rotated  inward  upon  the 
pronated  os  calcis,  is,  of  course,  not  plantar  flexed  nor  is  the 
anterior  extremity  of  the  os  calcis  depressed.  The  entire  foot  is 
simply  held  in  an  attitude  of  extreme  abduction  and  dorsal  flexion 
by  the  spasm  and  contraction  of  the  flexors  and  abductors,  so  that 
the  leg  must  be  bent  at  the  knee  and  inclined  forward  to  bring 
the  sole  to  the  ground.  Such  extreme  cases  are  uncommon. 
They  are  often  the  direct  result  of  injury,  so-called  chronic  sprain. 
Less  extreme  examples  of  this  class  are  very  common.  The  foot 
is  simply  turned  to  one  side  (valgus)  and  the  arch  appears  to  be 
depressed  because  of  the  attitude,  whereas  it  may  be  in  reality 
exaggeraterl  in  deptli. 

2.  Pes  Planus. — As  has  been  stated  already,  and  as  is  well- 
known,  there  is  a  type  of  painless  flat-foot  sometimes  called  pes 
planus,  in  whicli  tlie  flatness  of  the  foot  is  more  noticeable  than 
the  other  components  of  the  deformity  that  have  been  described. 
This  is  probably  the  result  of  inlieriterl  laxity  of  ligaments  or  of 
rhacliitis  or  other  form  of  acquiretl  weakness  in  early  life,  so  that 
a  normal  arch  was  never  present.  Such  a  foot  controlled  by 
normal  muscles  may  be  strong  and  cflicient,  but  it  is,  nevertheless 
deformed,  and  it  is  doubtful  if  its  possessor  ever  could  attain  the 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     693 

grace  and  elasticity  of  gait  possible  under  normal  conditions.  It 
is  said,  also,  that  a  low  arch  is  normal  in  certain  races,  for  example, 
the  negro,  but  the  American  negro  is  certainly  not  exempt  from 
the  pain  and  disability  inciflental  to  the  broken-down  foot. 

It  is  evident,  of  course,  that  the  breaking  down  of  a  properly 
shaped  foot,  supported  by  normal  ligaments,  will  be  attended 
by  greater  pain  and  greater  disability  than  of  one  in  which  the 
arch  was  originally  low  and  of  which  the  ligaments  were  weak, 
because  it  is  during  the  progression  of  the  deformity  and  particu- 
larly in  its  early  stages  that  such  symptoms  are  most  prominent. 

Fig.  443 


Weak  feet  and  slight  kunck-kuee 

\Mien  the  bones  of  the  arch  rest  upon  the  groiuid  or  when  final 
stability  has  become  assured,  pain  may  cease,  and  permanent 
accommodation  to  tlie  new  conditions  may  increase  tlie  ability  of 
the  deformed  meml)er.  Sucli  an  outcome  might  be  quickly 
accomplished  in  the  foot  originally  flat,  while  in  the  other  instance 
the  symptoms,  although  remitting  from  time  to  time,  might  con- 
tinue indefinitely. 

The  abducted  foot,  in  which  there  is  no  depression  of  tlic  arch, 
and  the  simple  flat-foot,  in  which  the  element  of  abduction  is  less 
prominent,  represent  the  two  extremes  of  weak  foot.  In  the 
majority  of  cases  tlie  two  are  combined  in  varying  degree. 


694  OETHOPEDIC  SUBGERY 

One  may  recognize,  then,  three  types  of  weak  foot  which  may  be 
classified  according  to  the  more  noticeable  deformity  as 

1.  Valgus,  or  abduction. 

2.  Valgo-planus,  or  abduction  and  depression. 

3.  Plano-valgus,  or  depression  and  abduction. 

This  distinction  is  of  some  importance  from  the  standpoint  of 
prognosis,  at  least  m  the  adolescent  and  adult  cases,  as  the  pros- 
pect of  anatomical  cure  corresponds  to  the  order  of  classification. 

Weak  Foot  in  Childhood. 

There  can  be  no  doubt  that  in  many  instances  the  origin  of  the 
weak  foot  may  be  traced  to  early  childhood.  Certainly,  deform- 
ities and  improper  attitudes  are  very  common  at  this  period,  and 
it  is  much  more  likely  that  they  are  ingrown  than  outgrown. 
Actual  pain  from  the  Aveak  foot  is  unusual  at  this  age.  The  child 
may  complain  of  fatigue  and  may  be  weak  and  awkward,  but 
it  is  usually  because  of  the  very  evident  deformity  rather  than 
because  of  symptoms  that  advice  is  asked.  In  these  cases,  as  in 
every  case,  the  habitual  attitudes  and  use  of  the  feet  are  of  the 
first  importance. 

Out-toeing  and  In-toeing  as  Symptoms  of  the  Weak  Foot  in 
Childhood.^— One  of  the  most  frequent  of  the  improper  postures 
is  that  of  exaggerated  outward  rotation  of  the  feet,  which  is  not 
only  an  ungraceful  attitude,  but  a  direct  cause  of  weakness  as  well. 
The  opposite  attitude  of  inward  rotation,  the  so-called  "pigeon- 
toed"  walk,  is  most  offensive  to  relatives  and  friends,  and  it  is 
for  correction  of  the  attitude  that  the  child  may  be  brought  for 
treatment.  The  attitude  is,  in  many  instances,  a  sign  of  the  weak 
foot,  for  on  examination  the  bulging  on  the  inner  side,  the  inward 
rotation  of  the  leg  in  its  relation  to  the  foot,  and  the  depressed 
arch  show  very  plainly  that  it  is  the  foot  and  not  the  attitude 
that  requires  treatment;  in  fact,  the  attitude  is,  in  this  class  of 
cases,  really  a  safeguard  against  increasing  deformity,  which  will 
correct  itself  when  its  cause  is  removed.'  Particular  emphasis  is 
laid  upon  this  point,  which  is  very  generally  overlooked,  because 
the  routine  treatment  of  the  "pigeon-toes"  in  these  cases  might 
be  tlie  cause  of  direct  harm. 

Weak  Ankles. — "Weak  ankle"  is  a  term  popularly  applied 
to  the  weak  foot  of  cliildhood,  in  which  the  foot  is  in  a  position 

'  Inward  rotation  of  the  limb,  an  attitude  controlled  by  the  muscles  at  the  hip,  and 
inversion  of  the  foot  are  usually  confounded.  Inward  rotation  of  the  limb  (pigoon-toe) 
and  aversion  of  the  foot  (weak  foot)  arc  often  combined  in  childhood. 


DISABILITIES  A^D  DEFORMITIES  OF  THE  FOOT     695 

of  valgus  when  in  use,  so  that  the  sole  of  the  shoe  is  worn  away  on 
its  inner  side.  Weak  ankles  are  very  common  in  young  children 
and  are  often  one  of  the  results  of  general  weakness  due  to  defec- 
tive assimilation.  At  this  age  the  foot  is,  in  addition,  usually 
flat  (Fig.  443),  but  in  the  valgus  or  weak  ankle  of  later  years 
the  arch  is  often  practically  normal  in  outline. 

Outgrown  Joints. — In  older  children  "outgro^ATi"  joints  often 
attract  the  mother's  attention;  tlie  internal  malleoli  appear  promi- 
nent because  of  the  position  of  valgus,  or  because  of  the  turning 
out  of  the  feet  the  malleoli  may  strike  against  one  another, 
"interfere,"  and  thus  there  may  be  an  actual  hypertrophy  of 
the  projecting  bones  from  local  irritation. 

Another  type  is  the  long,  slender  abducted  foot,  in  which  the 
inward  bulging  at  the  mediotarsal  joint  is  indicated  by  the  point 
of  wear  in  the  leather  of  the  shoe  (Fig.  440). 

In  the  weak  foot  of  childhood,  although  restriction  of  voluntary 
and  passive  motion  may  be  present,  there  are,  as  a  rule,  but  little 
local  sensitiveness  and  muscular  spasm,  and,  as  has  been  said,  but 
little  actual  pain,  for  the  reason  that  the  weak  foot  in  childhood  is 
not  subjected  to  the  stram  of  constant  occupation  or  to  the  burden 
of  an  overweighted  body.  There  is  also  another  important 
difference:  the  foot  of  the  adult  is  obliged  to  bear  greater 
strain  than  any  other  part,  and  although  normal  in  structure  it 
may  be  overworked,  so  that  m  many  instances  the  weakness  of 
the  foot  is  the  only  disability.  But  in  childhood,  when  such 
exciting  causes  are  absent,  a  weak  foot  is  very  often  a  local 
indication  of  general  weakness  and  loss  of  tone. 

Irregular  Forms  of  Weak  Feet. — Occasionally  the  apex  of 
the  inward  bulgmg  and  deformity  is  not  at  the  mediotarsal  joint, 
but  anterior  to  it  in  the  cuneiform  region.  In  such  cases  the 
internal  cuneiform  bone  may  be  enlarged  and  sensitive  to  pressure. 

Another  form  is  the  combination  of  a  plantar  flexed  toe  with  a 
depressed  arch  (Fig.  446).  Extreme  deformity  of  this  class  is 
usually  congenital.  A  milder  type  is  not  uncommon.  (See  Hallux 
Rigidus.) 

Weak  Feet  and  Deformity  of  the  Legs. — In  childhood  weak 
feet  are  often  seen  in  combination  with  slight  knock-knee  (Fig. 
443),  while  in  later  life  Icnock-knee  usually  induces  in  compensa- 
tion the  opposite  attitude  of  adduction.  (See  Knock-knee.) 
Bow-leg  in  childhood  is  usually  accompanied  by  slight  inward 
rotation  of  the  feet,  but  later  there  is  usually  a  certain  degree 
of  compensatory  valgus,  although  it  does  not,  as  a  rule,  cause 
discomfort. 


696 


ORTHOPEDIC  SUBQEBY 


General  Weakness. — The  direct  effects  of  the  weak  and  pain- 
ful foot  have  been  described  in  detail.  It  must  be  borne  in  mind 
that  the  feet  are  the  foundation  of  the  body,  and  that  an  insecure 
foundation  affects  the  entire  mechanism.  General  functional 
weakness  and  awkwardness,  the  flat  chest,  round  shoulders,  or 
other  curvatures  of  the  spine,  are  often  observed  as  accompani- 
ments or  effects  of  weak  feet.  Thus,  as  a  rule,  the  systematic 
treatment  of  any  form  of  postural  weakness  must  include  the 
treatment  of  the  feet  as  well. 

Recapitulation. — The  disability  and  deformity  of  the  weak 
or  so-called  flat-foot  are  caused  by  a  disproportion   between  the 


Fig.  444 


Fig.  445 


Congenital  flat-foot.  RiRid  deformity  of 
an  extreme  type,  illustrating  the  component 
abduction  and  (jbliteratioii  of  the  arch. 


Flat-foot  illustrating  extreme  deformity  in 
childhood. 


strength  of  the  foot  and  the  weight  and  strain  to  which  it  is  sub- 
jected. 

The  foot  may  be  weakened  l)y  injury  or  disease;  it  may  be 
overburdened  by  the  body  weiglit,  or  overstrained  by  laborious 
occupation,  or  the  l)rokeii-(lown  foot  may  be  simply  one  indica- 
tion of  general  bodily  weakness.  It  is  unnecessary  to  enumerate 
all  the  various  factors  that  singly  or  combined  lead  to  this  dis- 
ability. It  may  })e  stated,  liowever,  that  in  adult  life  tlie  weak 
foot  is  in  many  or  most  instances  the  only  disability  that  demands 
treatment.     Its  most  constant  predisposing  causes  are  the  direct 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      697 

injury  caused  by  improper  shoes  and  tlie  mechanical  disadvantages 
to  which  it  is  subjected  by  the  assumption  of  improper  attitudes. 

All  weak  or  flat  feet  are  mechanically  weak,  but  all  weak  feet 
are  by  no  means  painful  feet.  Pain,  the  symptom  of  over-strain 
or  injury,  bears  no  definite  relation  to  the  degree  of  deformity. 

In  certain  instances  persistent  abduction  of  the  f(Jot  may  be 
accompanied  by  exaggeration  of  the  arch ;  in  others,  the  flattening  of 
the  arch  may  be  the  most  noticeable  deformity,  but  in  most  cases 
the  two  are  combined  in  varying  degree.  And  as  eacli  deformity 
is  an  evidence  of  weakness,  it  seems  hardly  necessary  to  make  a 
radical  distinction  between  the  two,  except  as  regards  prognosis. 
For  the  abducted  foot  in  which  the  arch  is  intact  is  almost  always 

Tin.  446 


H:immer-t(ie  llat-fdnt. 


an  acquired  deformity  of  short  duration,  whereas  in  the  case  of 
the  foot  in  which  the  arch  is  obliterated  the  deformity  usually 
dates  from  early  childhood,  and  it  is,  therefore,  less  amenable  to 
treatment  as  far  as  perfect  cure  is  concerned. 

Treatment. — The  principles  of  the  treatment  which  leads  to 
the  permanent  cure  of  tlie  weak  and  deformed  foot  are  very 
simple,  but  the  application  varies  somewhat  according  to  the 
grade  and  tluration  of  tlie  deformity.  The  object  of  treatment 
is  to  so  change  the  weak  foot  that  it  may  conform  not  only  in 
contour  but  in  habitual  attitudes  and  m  power  of  voluntary 
motion  to  the  normal  foot,  because  complete  cure  is  impossible 
unless  normal  function  is  regained.  The  first  step  must  be, 
therefore,  to  make  passive  motion  free  and  painless  to  tlie  normal 


698  ORTHOPEDIC  SURGERY 

limit.  Ill  other  words,  the  obstructions  to  the  motion  of  the 
machine  must  be  removed  before  the  power  can  be  properly 
applied;  for  the  increase  of  muscular  strength  and  ability,  on 
which  ultimate  cure  depends,  is  not  possible  while  motion  is 
restrained  by  deformity  or  by  pain  or  by  adhesions  or  contractions. 

The  weak  foot,  because  of  inefficient  ligaments  and  muscles 
unable  to  hold  itseK  in  proper  position,  must  be  supported  until 
regenerative  changes  have  taken  place  in  its  structure.  Such  sup- 
port is  necessary  to  retam  the  joints  in  normal  position,  and  to 
hold  the  weight  in  proper  relation  to  the  foot,  otherwise  normal 
function  is  impossible.  AMien  these  essentials  are  provided  the 
patient  may  cure  himself  by  the  proper  functional  use  of  the 
foot  and  by  the  avoidance  of  attitudes  that  place  it  at  a  dis- 
advantage. 

It  may  be  well  to  describe,  first,- the  treatment  that  must  be 
applied  to  all  classes  of  weak  foot  in  which  a  cure  is  to  be  attempted 
and  which  by  itself  is  sufficient  in  the  milder  types,  before  calling 
attention  to  the  modifications  that  may  be  necessary  in  more 
advanced  cases. 

The  Shoe. — In  all  cases  it  will  be  necessary  to  provide  the 
patient  with  a  proper  shoe,  for  the  shoe  is  usually  the  direct 
cause  of  the  minor  deformities,  and  indirectly,  in  many  instances, 
of  more  serious  disability.  Indeed,  most  of  the  deformities  and 
disabilities  of  the  foot  are  incidental  to  civilization,  and  are,  there- 
fore, confined  to  the  shoe-wearing  people.  The  direct  effect  of  the 
ordinary  shoe  is  to  lessen  the  area  and  the  adjustability  of  the 
fulcrum  by  cramping  the  toes.  Indirectly  it  causes  deformities — 
corns,  bunions,  and  the  like — which  serve  to  make  active  move- 
ment or  leverage  painful,  so  that  it  is  replaced  by  the  passive 
attitude. 

The  proper  shoe  should  contain  sufficient  space  for  the  inde- 
pendent movements  of  the  toes.  This  motion  is  illustrated  in  the 
walk  of  the  barefoot  child.  As  the  weight  falls  on  the  foot  the 
toes  spread,  and  as  the  body  is  raised  on  the  foot  they  contract. 
The  important  leverage  action  of  the  great  toe  and  the  support 
afforded  by  it  to  tlie  arch  of  the  foot  have  been  mentioned  already. 
The  shape  of  the  sole  should  correspond  to  the  shape  of  the 
foot  and  the  heel  shoidd  be  broad  and  low.  It  will  be  noted  that 
the  front  of  the  sole  of  the  shoe  in  (Fig.  447)  appears  to  be 
pointed  slightly  inward.  Such  a  shoe  aids  in  preventing  abduc- 
tion, and  it  is,  therefore,  an  important  adjunct  to  the  brace  in 
restraining  deformity. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      699 


Fig.  447 


Raising  the  Inner  Border  of  the  Shoe. — A  simple  expedient  in 
the  treatment  of  the  weak  foot  and  an  aid  in  balancing  it  properly 
is  to  make  the  inner  border  of  the  sole  and  heel  of  the  shoe  slightly 
thicker  in  order  to  throw  the  weight  toward  the  outer  side  of  the 
foot.  Tliis  is  of  special  importance  in  the  treatment  of  the  slighter 
degrees  of  what  is  known  as  weak  ankle,  and  it  is  always  of  ser- 
vice in  the  treatment  of  any  grade  of  weak  foot. 

Attitudes. — ^T.lie  patient's  attention  is  then  called  to  the  signifi- 
cance of  the  bulging  on  the  inner  side  of  the  foot  (Fig.  441)  and 
how  this  may  be  prevented  by  throw- 
ing the  weight  on  the  outer  side  of  the 
foot  (Fig.  442)  and  by  holding  the  feet 
parallel  with  one  another  in  walking 
(Fig.  417).  The  importance  of  lever- 
age is  shown  him,  that  he  must  try  to 
press  down  the  sole  of  the  shoe  with 
his  toes,  particularly  with  the  great 
toe,  and  employ  the  active  lift  of  the 
calf  muscles  by  fully  extending  the  leg 
and  raising  the  body  on  the  foot  from 
time  to  time  (Fig.  417).  Finally,  he 
must  avoid  long  continuance  in  one 
position,  especially  the  passive  posture, 
which,  even  in  the  normal  subject, 
simulates  the  attitude  and  deformity 
of  weak  foot.  In  short,  he  must  be 
instructed  in  the  mechanics  of  the  foot 
and  taught  how  the  weak  foot  may  be 
protected  as  well  as  strengthened. 

Exercises. — It  is  important,  also,  to 
demonstrate  to  the  patient  the  normal 
range  of  motion  of  the  foot,  motion 
which,  if  restricted,  must  be  regained 
by  voluntary  and  passive  exercises. 
Voluntary  exercise  should  be  devoted 
to  strengthening  the  adductors  and 
plantar  flexors;  thus  the  foot  shoukl 
be  adducted  and  inverte;!,  then  dorsi- 
flexed  in  the  attitude  of  slight  adduction  (Fig.  421)  over  and 
over  again  at  every  opportunity.  Tip-toe  exercises  are  especially 
useful;  the  patient,  placing  the  feet  in  the  attitude  of  moderate 
inward    rotation,    raises    the   body   on    tlie  toes  to  the  extreme 


The  proper  relation  of  the  sole  to 
the  shape  of  the  foot:  A,  outline 
of  sole;  B,  outline  of  foot;  C,  im- 
print of  foot. 


700 


ORTHOPEDIC  SURGERY 


limit,  tlie  limbs  being  fully  extended  at  the  knees,  then  smking 
slowly,  resting  the  weight  on  the  outer  borders  of  tlie  feet,  in 
the  attitude  of  marked  varus,  twenty  to  one  hundred  times.  This 
exercise  is  somewhat  difficult,  and  it  cannot  be  carried  out 
properly  if  tliere  is  any  limitation  of  motion  or  sensitiveness  at 
the  mediotarsal  jomts.  The  best  of  all  exercises  is,  however,  the 
proper  walk,  in  which  the  leverage  power  of  the  foot  is  employed 
and  in  which  it  passes  through  the  proper  alternation  of  postures 


Fig.  448 


Fig.  449 


The  tip-toe  exerci.se,  raising  the  Ixjciy  on  tlie 
adductecJ  feet.     (See  Fig.  449.) 


The  tip-toe  exercise,  resting  on  the  outer 
borders  of  the  feet.     (See  Fig.  448.) 


(Fig.  417).  Treatment  by  massage  and  special  gymnastic  exer- 
cises is,  of  course,  of  benefit  if  the  patient  can  command  it,  although 
by  no  means  essential  to  the  cure. 

Support. — In  many  instances  the  simple  treatment  that  has  been 
outUned  is  all  that  is  refjuired,  l)ut  in  the  majority  of  cases  the 
patient  is  not  able  to  prevent  deformity  voluntarily;  consequently 
a  support  is  necessary  to  hold  the  foot  in  proper  position  and  to 
relieve  discomfort.     It  is  usually  necessary  in  the  treatment  of  the 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     701 

weak  foot  of  childhood  because  one  cannot  command  the  aid  of 
the  patient. 

In  selecting  a  support  for  the  weak  foot  the  nature  of  the 
deformity  should  be  borne  in  mind;  that  the  acquired  flat-foot, 
for  example,  is  not  a  direct  breaking  down  of  the  arch,  as  is 
usually  taught,  but  a  lateral  deviation  and  sinking — a  compound 
deformity,  as  has  been  already  described  (Fig.  436).  Thus  a 
brace  to  be  efficient  must  hold  the  foot  laterally  as  well  as  support 
the  arch.  But  it  must  not  prevent  the  normal  motions  of  the  foot, 
and  thus  interfere  witli  the  increase  of  muscular  strength  and 
ability,  on  which  ultimate  cure  depends. 

The  supports  that  are  ordinarily  used  for  flat-foot  do  not  fulfil  the 
conditions;  the  pads,  springs,  and  plates  placed  beneath  the  arch 
are  intended  to  support  it  by  direct  pressure  without  regard  to  the 


Fig.   450 

■i 

VH 

■■■ 

Vl' 

--%..^^ppn 

!^T^^5ilHWB^^^'^'  \3 

^1— 

^^  ■  --■■*-»«« 

"-— ^ 

The  attitude  in  wliich  the  phister  cast  should  be  taken.  This  attitude  is  important, 
because  in  it  the  foot  assumes  the  best  possible  contour.  If  the  sole  is  simply  pressed 
downward  into  the  plaster  cream,  the  ordinary  method  of  making  the  model,  the  shape 
will  be  found  to  be  quite  different  from  that  taken  in  the  manner  illustrated. 


abduction ;  they  are  usually  ill-fitting,  and  are  often  of  such  length 
and  shape  as  to  splint  the  foot  and  thus  to  restrict  its  motion. 
Leg  braces  which  control  the  valgus  do  not  often  hold  the  foot 
accurately,  and  their  weight  and  unsightliness  are  fatal  objec- 
tions to  their  use,  especially  in  the  early  cases,  in  which  pre- 
vention of  subsequent  deformity  is  of  such  importance. 

A  brace  should  never  be  applied  to  a  deformed  and  rigid  foot 
because  it  cannot  adapt  itself  to  the  support;  the  spasm  and 
rigidity  should  be  first  relieved  by  the  preliminary  treatment, 
that  will  be  described  in  the  consideration  of  this  class  of  cases. 

The  Construction  of  the  Brace. — To  properly  construct  a  brace 
to  meet  these  conditions,  it  is  necessary'  to  provide  the  mechanic 
with  a  plaster  cast  of  the  foot,  taken  in  the  attitude  in  which  one 
wishes  to  support  it.  Such  a  model  may  be  easily  and  quickly 
made  in  the  following  manner: 


702  OBTHOPEDIC  SUBGEBY 

The  Plaster  Cast. — Seat  the  patient  in  a  chair;  in  front  of  him  place 
another  chair  somewhat  less  m  height;  on  it  lay  a  thick  pad  of  cot- 
ton-batting and  cover  it  with  a  square  of  cotton  cloth.  Put  about 
a  quart  of  cold  water  into  a  basin  and  sprinkle  plaster-of-Paris 
on  the  surface  until  it  does  not  readily  sink  to  the  bottom;  then 
stir.  AYhen  the  mixture  is  of  the  consistency  of  very  thick  cream 
pour  it  upon  the  cloth.  The  patient's  knee  is  then  flexed,  and 
the  outer  side  of  the  foot,  previously  rubbed  with  talcum  powder, 
is  allowed  to  sink  into  the  plaster,  and,  the  borders  of  the  cloth 
being  raised,  the  plaster  is  pressed  against  the  foot  until  rather  more 
than  hah  is  covered.  The  foot  should  be  at  an  angle  wdth  the  leg, 
corresponding  to  its  usual  position  in  the  shoe,  that  is  slightly 
plantar  flexed,  and  the  sole  should  be  in  the  plane  perpendicular 
to  the  seat  of  the  chair  (Fig.  450).     As  soon  as  the  plaster  is  hard 

JiiG.   451 


A,  the]  astragalonavicular  joint.     The  internal  flange  of  the  brace  should  rise  well  above 
all  the  prominent  bones  to  a  point  about  half  an  inch  below  the  malleolus, 

its  upper  surface  is  coated  with  vaseline,  and  the  remainder  of 
the  foot  is  covered  with  plaster;  the  two  halves  are  then  removed, 
smeared  lightly  with  vaseline,  and  bandaged  together.  The 
interior  is  dampened  with  soapsuds,  and  it  is  then  filled  with 
the  plaster  cream.  In  a  few  moments  the  plaster  shell  may  be 
removed,  and  one  has  a  reproduction  of  the  foot,  which,  when 
properly  made,  should  stand  upright  without  inclination  to  one 
side  or  the  other  (Tig.  454). 

In  most  instances  it  will  be  of  advantage  to  deepen  in  the  plaster 
model  the  inner  and  outer  segments  of  the  arch,  in  order  that 
the  arch  of  the  brace  may  be  slightly  exaggerated,  especially 
at  the  heel,  so  that  the  depression  of  the  anterior  extremity  of 
the  OS  calcis  may  be  prevented.  If  the  outer  border  of  the  cast 
is  flattened  by  pressure  a  little  plaster  should  be  added  to  approxi- 
mate the  normal  contour. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      703 


The  Brace. — Upon  the  model  the  outHne  of  the  brace  is  drawn 
as  ilkistrated  in  the  diagrams.  The  best  sheet  steel,  IS  to  20 
gauge,  cut  after  the  pattern  is  moulded  upon  it  and  tempered,  so 
that  as  it  is  appHed  for  the  purpose  of  preventing  deformity,  it 
may  be  practically  unyielding  to  the  weight  of  the  body. 

It  will  be  noticed  that  the  brace  clasps  the  weak  part  of  the  foot 
and  holds  it  together;  the  broad  internal  upright  portion  (Fig. 
451)  covers  and  protects  the  astragalonavicular  junction,  rising 
well  above  the  navicular;  the  external  arm  covers  the  calcaneo- 
cuboid junction  and  the  outer  aspect  of  the  foot  to  a  height  suflfi- 
cient  to  hold  the  foot  securely  (Fig.  452).     The  sole  part  provides 


Fia.  452 


Fig.   453 


B,  the  calcaneocuboid  junction.  The  external  flange 
extends  from  the  centre  of  the  heel  to  a  point  just  be- 
hind the  base  of  the  fifth  metatarsal  bone. 


C,  the  great  toe-joint;  D,  the 
centre  of  the  heel. 


a  firm,  comfortable  support,  yet,  reaching  only  from  the  centre 
of  the  heel  to  just  behind  the  ball  of  the  great  toe,  it  does  not 
restrain  the  normal  motions  of  the  foot  (Fig.  453).  The  brace 
may  be  nickel-plated  which  makes  a  smooth  finish,  or  galvanized, 
which  makes  a  more  durable  covering.  It  mav  be  covered  with 
leather,  or  an  inner  sole  msjy  be  placed  on  its  upper  surface; 
but  this  is  not  usually  necessary.  As  it  is  fitted  to  the  foot,  it 
finds  and  holds  its  own  place  in  the  shoe,  so  that  no  attachment 
is  required;  thus  it  may  be  changed  from  one  shoe  to  another. 
Not  only  does  it  hold  the  foot  laterally  and  from  beneath,  but 
there  is  an  element  of  suggestiveness  in  the  slight  leverage  action 
which  is  very  important,  and  which  is  a  distinctive  feature  of 
this  brace  as  contrasted  with  simple  sole  plates  or  other  supports. 


704 


OR  TH  OPE  Die  S  UR  GER  T 


The  Positive  Action  of  a  Proper  Brace. — The  patient,  instructed 
to  throw  his  weight  upon  the  outer  side  of  the  foot  and  wear- 
ing the  shoe  which  has  been  tihed  in  the  same  direction  by 
thickening  the  inner  border  of  the  sole  and  heel,  presses  down 
the  external  arm  and  thus  lifts  the  internal  flange  against  the 
inner  side  of,  the  foot,  which  is  instinctively  drawn  away  from 
the  pressure  and  thus  toward  the  normal  contour.  He  no  longer 
turns  the  feet  outward  in  walldng,  because  this  causes  positive 
discomfort,  and  he  is  not  Ukely  to  assume  the  passive  attitude 
because  of  the  suggestive  lateral  pressure  of  the  support.  With 
the  foot  held  in  the  normal  attitude  the  patient  may  again  walk 
^^'ith  the  proper  spring;  thus  the  brace  itself  becomes  a  positive 
aid  in  the  physiological  cure.     It  is  important,  also,  that  a  shoe 

Fig.   454 


A  cast  marked  for  the  mechanic.  In  most  instances  the  internal  flange  is  lengthened  as 
in  this  diagram,  as  compared  with  Fig.  451,  in  order  to  strengthen  the  support  so  that  light 
steel  (gauge  20)  may  be  used.     (See  Fig.  455.) 

of  proper  shape,  as  shown  in  the  diagram  (Fig.  447),  be  worn, 
as  it  aids  the  brace  in  holding  the  foot  in  an  attitude  of  slight 
adduction. 

The  shape  of  the  brace,  in  general  like  that  of  the  diagram,  is 
modified  in  certain  cases;  for  instance,  the  entire  internal  aspect 
of  the  foot  may  be  weak  and  must  be  covered  by  the  internal 
flange.  In  very  heavy  subjects  the  sole  portion  must  be  made 
larger,  although  this  is  a  disadvantage,  as  it  lessens  the  leverage 
action;  other  slight  modifications  may  be  necessary  in  special 
cases.  If  any  portion  of  the  rim  of  the  brace  causes  discomfort, 
the  edge  may  be  turned  away  slightly  at  the  point  of  pressure  by 
a  wrench.  After  a  few  days  the  patient  no  longer  notices  the 
constraint  of  the  brace,  and  as  its  presence  in  the  shoe  is  not 
evident,  it  may  be  worn  •indefinitely.     Steel  is  the   lightest  and 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     705 


Fig.  455 


strongest,  and,  on  the  whole,  the  most  satisfactory  material  for  the 
brace.  It  will,  of  course,  rust  in  time,  and  for  this  reason  each 
patient  may  be  provided  with  two  pairs  of  braces,  in  order  that 
the  rusted  pair  may  be  returned  to  the  bracemaker  for  repairs. 
In  hospital  practice  heavier  material  is  used  and  the  braces  are 
plated  with  tin,  which  is  fairly  resistant.^ 

Support  is  usually  necessary  for  from  three  months  to  a  year  or 
longer  according  to  the  condition  of  the  patient  and  the  strain  to 
which  the  feet  are  subjected.  The  brace,  accurately  made  and  ad- 
justed under  suitable  conditions, 
causes  no  more  pressure  or  dis- 
comfort than  a  well-made  shoe,  for 
its  principle  is  quite  different  from 
that  of  the  ordinary  supports  that 
are  in  common  use,  to  which  this 
objection  has  been  made.  This 
brace  supports  the  arch  primarily 
by  preventing  abduction,  con- 
sequently its  pressure  is  first  felt 
upon  the  lateral  aspect  of  the  foot, 
a  pressure  that  the  patient  can 
relieve  by  improving  his  attitude. 
The  brace  should  afford  support 
when  necessary,  and  at  all  times 
suggest  and  enforce  a  proper 
attitude;  it  is,  however,  but  oneof 
the  essential  factors  in  the  general 
scheme  of  treatment.  The  ordinary  form  of  brace  in  all  its  modi- 
fications conforms  to  the  shape  of  an  inner  sole  (Fig.  456).  As  it 
supports  the  sole  of  the  foot,  and  by  the  elevation  of  its  inner[border 


The  outline  of  the  sole  part  of  the  brace. 


Fig.  456 


The  sole  plate  ordinarily  used  in  the  treatment  of  weak  foot.     (After  Bradford  and  Lovett.) 


tends  to  throw  the  weight  more  toward  the  outer  side,  it  is  a 
useful  aid  in  treatment;  but,  providing  no  lateral  support,  it  cannot 
prevent  the  inward  bulging  of  the  foot,  which  is  the  most  im- 

1  In  many  instances  there  is  a  rapid  improvement  in  the  shape  of  the  foot  imder  treatment, 
and  it  is  often  advisable  to  make  a  second  cast  in  such  case9,  i|i  order  that.tl^e  brace  m^y 
conform  to  the  improved  contour, 

45 


706  ORTHOPEDIC  SURGERY 

portant  element  of  the  deformity,  and  as  compared  to  the  brace 
described,  it  is  therefore  an  ineffective  apparatus. 

In  the  treatment  of  children  the  foot  should  be  moved  in  all 
directions,  but  particularly  in  dorsal  flexion  and  adduction  to  the 
full  limit  at  morning  and  at  nieht,  imtil  the  child  has  regained 
the  normal  muscular  power  and  ability.  Special  gymnastics  and 
massage  are  always  desirable,  and  they  may  be  necessary  in 
certain  cases.  Bicvclino-  may  be  cited  as  one  of  the  best,  and 
roller-skating  as  one  of  the  worst  exercises  for  the  weak  foot. 
A  year  is  about  the  time  required  for  a  cure  of  the  weak  foot  in 
childhood,  although  attention  to  the  shoes  and  to  the  attitudes 
must  be  continued  indefinitely. 

The  Rigid  Weak  Foot. 

One  may  now  contrast  with  the  mild  types  of  weakness  that 
have  been  described  the  cases  of  extreme  deformity  in  which 
the  symptoms  are  disabling  and  in  which  the  foot  is  rigidly  held 
in  the  deformed  position  by  muscular  spasm  and  by  secondary 
changes  in  its  structure.  Such  cases,  often  considered  hopeless 
as  regards  a  cure  or  even  relief,  are  in  reality  the  most  satisfac- 
ioTj  from  the  remedial  standpoint,  and  in  no  other  type  of  pain- 
ful deformity  can  so  much  be  accomplished  by  rational  treatment 
as  in  this  class.  The  deformity  must  be  considered  as  a  disloca- 
tion in  which  the  astragalus  has  slipped  downward  and  inward 
from  off  the  os  calcis,  which,  in  turn,  is  tipped  downward  and 
inward  and  into  a  position  of  valgus.  The  remainder  of  the 
foot  is  turned  outward,  so  that  the  relation  of  the  leg  and  the 
forefoot  is  entirely  changed;  in  fact,  the  forefoot  is  almost  entirely 
disused  (Fig.  445). 

Corresponding  to  the  duration  of  the  disability,  one  finds 
accommodative  changes  in  the  soft,  parts  and  in  the  bones,  but 
such  changes  are  by  no  means  as  marked  as  those  recorded  in  the 
reports  of  autopsies  which  have  been  made  in  cases  of  advanced 
and  irremediable  deformity.  In  fact,  by  far  the  greater  number  of 
patients  are  young  adults  in  whom  the  extreme  deformity  is  of  com- 
paratively short  duration,  and  in  whom  complete  cure  is  possible. 

In  the  treatment  of  such  a  condition  one  must  first  reduce  the 
dislocation  and  oven.-ome  the  obstacles  that  contracted  muscles  and 
ligaments  may  offer  to  free  and  normal  motion ;  then  rest  must 
be  assured  to  the  injured  and  congested  parts  in  order  to  relieve 
the  patient  from  the  pain  from  which  he  has  suffered  so  long. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     707 

Forcible  Overcorrection. — By  far  the  most  effec-tive  treatment  is 
forcible  overcorrection  of  the  deforuiit}',  under  ana?sthesia.  When 
the  patient  is  under  the  influence  of  the  anaesthetic  the  muscular 
spasm  relaxes,  and  it  will  be  seen  that  this  accounts  for  about 
half  of  the  restriction  of  motion,  the  remainder  being  caused  by  the 
adaptive  changes  that  have  been  mentioned.  The  object  of  the 
operation  is  to  overcome  the  residual  obstruction,  and  to  assure 
the  patient  against  a  relapse,  by  fixing  the  foot  for  a  sufficient 
time  in  the  position  of  extreme  adduction  and  supination,  the 
attitude  directly  opposed  to  that  which  has  become  habitual. 

This  is  the  object  of  forcible  overcorrection  as  the  first  step  in 
the  systematic  repair  of  the  disabled  mechanism;  its  principle 

Fig.   457  ,  Fig.   458 


The  deformed  foot  before   operation.      A,    the  The  overcorrected  foot,  showing  the 

projection  of  the  tlisiilaced  astragalus  and  navic-         reversal  of  the  lines  of  displacement, 
ular;    B,    the    inner    malleolus;  C,   the   medio-         (See  Fig.  459.) 
tarsal  joint,  showing  the  outward  displacement 
before,  the  inward  rotation  behind,  this  point. 

must  not  be  confounded  with  forcible  correction  carried  out  with 
the  object  of  simply  remoulding  the  arch  of  the  foot,  or  in  which 
the  correction  of  the  deformity  is  the  only  object  in  view. 

One  first  extends  the  foot  forcibly,  then  flexes  it  to  the  normal 
limit,  then  abducts  and  adducts,  the  different  motions  being 
carried  out  over  and  over  until  the  rigid  foot  has  become  perfectly 
flexible.  In  cases  of  long  standing  it  is  often  necessary  to  draw 
the  patient  to  the  end  of  the  table,  so  that  the  foot  may  be  taken 
between  the  knees,  in  order  to  supply  the  required  force  by  the 
thigh  muscles.  This  forcible  manipulation  is  accompanied  by  the 
audible  breaking  of  adhesions,  and  in  favorable  cases  by  complete 
disappearance  of  the  deformity.     In  certain  instances  it  will  be 


708  OR  TROPE  Die  SURGERY 

necessan^  to  di-side  the  tendo  Achillis,  when,  for  example,  the 
range  of  dorsal  flexion  is  Hmited  bv  resistant  accommodative 
shortening  of  the  calf  muscles,  or  when  there  has  been  very  great 
pain  and  tenderness  at  the  mediotarsal  joint,  and  it  is  desired  to 
remove  the  strain  of  leverage  completely;  traumatic  cases  come 
especially  under  this  head.  Tenotomy  has  one  great  advantage: 
it  necessitates  longer  fixation  in  the  plaster  bandage,  and  gives 
the  patient  the  benefit  of  rest,  and  the  opportunity  for  prolonged 
after-treatment.  When  the  passive  range  of  motion  has  been 
regained,  the  foot  is  turned  dowTiward,  then  inward  and  upward 
into  the  position  of  extreme  varus.  By  this  manipulation  the  os 
calcis  is  dra^uTi  under  the  astragalus  and  thrown  into  the  supinated 
position,  and  the  ravicular  is  flexed  about  and  under  the  head  of 
the  astragalus,  which  is  then  lifted  to  the  limit  of  normal  flexion. 
The  attempt  is  always  made  to  bring  the  extreme  outer  border 
of  the  inverted  foot  up  to  a  right  angle  with  the  leg,  which  is  the 
limit  of  normal  flexion  in  this  attitude.  The  foot,  very  thickly 
padded  with  cotton,  especially  between  and  about  the  toes,  is  then 
fixed  in  this  posture  of  varus  by  a  firm  plaster-of-Paris  bandage 
extending  to  the  knee  (Fig.  459).  Surprisingly  Httle  discomfort, 
considering  the  force  that  it  is  sometimes  necessary  to  apply,  is 
experienced  after  the  operation.  The  familiar  and  often  intense 
pain,  from  which  the  patient  has  suffered  so  long,  is  entirely 
relieved  by  the  correction  of  the  deformity;  there  is  often  a  sense 
of  tension  about  the  outer  side  of  the  ankle  and  dorsum  of  the 
foot,  but  this  is  not,  as  a  rule,  of  long  duration. 

Functional  Use  in  the  Overcorrected  Attitude. — As  soon  as  pos- 
sible, often  on  the  following  day,  the  patient  is  encouraged  to  stand 
and  walk,  bearing  his  weight  on  the  foot.  Weight  bearing  serves 
to  still  further  overcorrect  the  deformity  and  to  accustom  the 
patient  to  a  posture  entirely  different  from  that  so  long  assumed. 
Meanwhile,  the  contracted  tissues  on  the  outer  side  become 
thoroughly  overstretched;  the  weakened  ligaments  and  muscles 
on  the  inner  side  are  relaxed,  and  the  local  irritation  rapidly 
subsides  under  the  rest  from  the  constant  injury  to  which  the 
foot  has  been  subjected. 

I'he  patient  is  not  confined  to  the  bed  or  house,  although  if 
both  feet  are  in  plaster  bandages,  crutches  are,  of  course,  neces- 
sary. The  time  that  the  foot  should  remain  in  the  overcorrected 
position  depends  upon  the  duration  of  the  deformity  and  the 
severity  of  the  symptoms,  from  two  to  six  weeks,  the  usual 
time  being  about  four  weeks.     At  the  end  of  about  three  weeks, 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     709 


Fig.  459 


or  whenever  the  patient  can  support  the  weight  on  the  plaster 
bandage,  without  a  sensation  of  discomfort,  it  is  removed;  the 
foot  is  placed  in  the  normal  attitude  and  a  cast  is  taken  for 
the  brace  (Fig.  450).  Immediately  after,  the  foot  is  returned 
to  the  former  position  and  the  plaster  bandage  is  reapplied. 
When  the  brace  is  ready  the  plaster  bandage  is  finally  removed; 
the  foot  is  now  in  good  position,  and  in  many  instances  the  arch 
is  exaggerated  in  depth.  For  the  first  few  days  prolonged  soak- 
ing in  hot  water  or  the  use  of  the  hot-air  bath,  with  subsequent 
massage  at  intervals  during  the 
day,  will  be  found  useful  in  over- 
coming the  swelling  and  sensi- 
tiveness that  may  remain.  It  is 
always  insisted  that  a  new  shoe 
of  the  Waukenphast  pattern  shall 
be  obtained,  the  sole  and  heel  of 
which  are  raised  a  quarter  of  an 
inch  on  the  inner  border  to  aid 
in  the  balancing  of  the  weak 
foot.  The  brace  is  then  applied , 
and  the  patient  is  never  allowed 
to  walk  without  its  support. 
When  the  shoe  is  removed  at 
night,  he  is  instructed  to  turn 
the  toes  in  and  to  bear  the 
weight  on  the  outer  side  of  the 
foot  until  it  has  regained  its 
strength ;  in  other  words,  the  de- 
formity is  never  allowed  to  recur. 
Systematic  Manipulation. — 
Systematic  treatment  is  then 
begun  by  the  surgeon  and  the 
patient,  with  the  object  of  re- 
storing free  and  painless  passive  movement  in  all  directions.  This 
movement,  which  has  been  so  long  restrained  by  deformity,  cannot 
be  regained  without  effort,  and  during  this  critical  stage,  treat- 
ment must  be  carried  out  by  the  surgeon  himself;  if  he  trusts  to 
the  patient  or  to  his  friends  a  cure  is  out  of  the  question.  At 
least  once  a  day  the  full  range  of  motion  must  be  carried  out  to 
the  normal  limit.  Three  motions — abduction,  flexion,  and  exten- 
sion— are  usually  free  and  painless;  but  the  fourth,  that  of 
adduction,  is  almost  invariably  resisted  by  the  same  quality  of 


The  forcible  overcorrection  of  fliit-foot.    The 
proper  position  in  the  plaster  bandage. 


10 


OR  TH  OPE  Die  SUBOERY 


muscular  rigidity  that  was  present  before  the  operation.  Per- 
haps the  only  effective  method  of  overcoming  this  resistance  is 
conducted  as  follows:  The  patient  being  seated  in  a  chair,  the 
surgeon  sits  or  stands  before  him.  Let  us  suppose  that  the 
right  foot  is  to  be  adducted,  or,  as  the  patients  express  it,  twisted. 


Fig.  460 


ling"  (ho. fool,. 


The  surgeon  places  the  foot  between  his  knees;  his  right  hand 
encircles  the  heel,  the  fingers  grasping  the  projecting  os  calcis 
and  tendo  Acliillis;  the  base  of  the  palm  lies  against  the  medio- 
tarsal  joint  on  the  inner  and  inferior  aspect  of  the  foot;  the  left 
hand  grasps  the  outer  side  of  the  forefoot  and  toes;  then,  by 
steady  pressure  of    the  thigh    nuiscles,  the  forefoot    is    forced 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     711 

downward  and  inward  (adducted  and  supinated)  (Fig.  460)  over 
the  fulcrum  formed  by  the  projecting  palm,  which  lies  upon  the 
right  knee,  the  fingers  holding  the  heel  steadily  in  place.  This 
inward  twisting  is  at  first  resisted  by  voluntary  and  involuntary 
muscular  spasm,  which  gradually  gives  way  under  steady  pres- 
sure. When  the  limit  of  adduction  has  been  reached,  the  foot 
is  held  firmly  until  all  pain  has  subsided;  then  the  patient  is  in- 
structed to  attempt  voluntary  movements  while  the  foot  is  guided 
by  the  hands;  in  other  words,  the  patient  attempts  to  adduct 

Fia.  461 


Method  of  applying  the  plaster  strapping  to  hold  the  foot  in  the  adducted  attitude. 

the  foot  while  the  surgeon  supplies  the  power,  which  in  all  cases 
of  this  type  has  been  completely  lost.  This  passive  manipula- 
tion to  the  extreme  limit  of  normal  adduction,  plantar  and  dorsal 
flexion,  is  continued  from  day  to  day  until  there  is  no  longer  a 
sensation  of  pain  or  tension.  For  as  long  as  there  is  the  slightest 
spasm  or  painful  restriction  of  passive  motion,  the  voluntary 
assumption  of  proper  attitudes  is  checked,  and  until  this  power 
is  regained  there  is  danger  of  relapse.  During  active  treatment, 
therefore,  the  patient,  by  means  of  massage  and  active  and  pas- 
sive exercises,  must  constantly  work  to  one  end,  namely,  to  regain 
the  lost  power  of  voluntary  adduction. 


712  ORTHOPEDIC  SURGERY 

The  time  necessary  to  rest  the  feet,  to  overcome  the  local  irrita- 
tion and  muscular  spasm,  to  regain,  in  part  at  least,  the  range 
of  passive  motion,  and  to  place  the  patient  in  the  same  position, 
as  regards  a  cure,  as  in  the  milder  types  of  deformity,  is  from 
three  to  six  weeks.  Usually  the  patients  are  told  that  a  month 
"U'ill  be  necessary,  and  that  at  the  end  of  that  time  they  may  return 
to  work,  free  from  pain  and  from  the  danger  of  relapse,  and  that 
the  feet  will  constantly  grow  stronger  under  the  work  which  was 
before  too  great  for  their  strength.  The  time  necessary  to  re- 
educate the  adductor  muscles  in  their  proper  function  depends, 
in  great  degree,  upon  the  intelligence  and  persistence  of  the  patient. 
xA.lthough  in  after-treatment  massage  and  special  exercises  are 
of  benefit,  the  essentials  are  very  simple;  they  are  an  ejEfective 
brace,  a  proper  shoe,  the  passive  manipulation  that  has  been 
described  until  its  object  has  been  attained,  and  the  proper  walk, 
the  best  and  easiest  of  exercises.  Finally,  one  must  force  into 
the  patient's  understanding  the  method  of  protecting  the  weak 
foot  by  the  alternation  of  strain,  and  by  proper  postures. 

Other  Varieties  of  Rigid  Weak  Foot. — The  foot  which  is  fixed 
in  the  abducted  position  without  depression  of  the  longitudinal 
arch  is  simply  one  variety  of  the  rigid  weak  foot,  which  should 
be  treated  in  the  same  manner.  It  may  be  stated,  also,  that  a 
yery  large  proportion  of  the  so-called  chronic  sprains  of  the  ankle 
are  of  this  type,  and  that  the  disability  will  yield  very  readily  to 
treatment,  conducted  with  the  purpose  of  restoring  impaired  func- 
tion, in  the  manner  that  has  been  indicated. 

In  certain  instances  the  apex  of  the  deformity  lies  in  front 
of  the  astragalonavicular  joint,  in  the  navicular  cuneiform  region, 
and  the  internal  cuneiform  bone  may  be  enlarged  and  sensitive 
to  pressure.  Such  cases  should  be  treated  on  the  same  general 
principles  as  the  ordinary  variety. 

In  rare  instances  marked  depression  of  the  arch  is  accompanied 
by  flexion  contraction  of  the  great  toe,  as  if  the  result  of  an  attempt 
to  support  the  weak  arch.  This  was  described  by  Nicoladoni 
as  hammer-toe  flat-foot  (Fig.  446).  The  association  of  painful 
great  toe  (hallux  rigidus)  and  weak  foot  is  mentioned  elsewhere 
(page  735). 

There  are  other  cases  in  which  the  deformity  of  weak  foot  is 
complicated  by  rheumatoid  arthritis  or  chronic  rheumatism,  or 
similar  affections  of  which  the  evidence  is  seen  in  various  joints, 
but  in  which  the  pain  and  discomfort  seem  to  be  concerftrated 
in   the  feet,  which  are  absolutely  stiff  and   deformed.     In  such 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      713 

cases  one  can  hardly  expect  a  complete  cure;  but  although  the 
function  of  leverage  may  not  be  regained,  still  one  may  hope,  by 
overcoming  the  deformity,  to  hold  the  weight  of  the  body  in  its 
proper  relation  to  the  foot,  so  that  the  pain  of  a  progressive  dis- 
location may  not  be  added  to  the  pain  of  disease.  In  a  number 
of  instances  forcible  correction  has  been  employed  by  the  writer 
in  cases  of  this  type,  and  in  all  the  improvement  in  the  general 
condition,  consequently  in  the  resistance  to  the  disease,  after  the 
relief  of  the  local  pain  and  discomfort,  has  been  very  great. 

Between  the  two  classes  of  cases,  the  mild  and  the  severe,  one 
finds  every  grade  of  deformity.  All  cases  in  which  there  is  marked 
muscular  spasm,  local  sensitiveness,  and  swelling  require  tem- 
porary rest;  in  many  instances  simply  rest  from  functional  use 
combined  with  massage;  in  others,  rest  in  a  plaster  bandage 
in  the  adducted  attitude.  In  the  milder  and  ordinary  class  of 
cases  the  use  of  a  brace  and  shoe  will  reUeve  spasm  and  pain, 
and  the  range  of  motion  can  usually  be  regained  by  manipulation, 
passive  motion,  and  by  the  proper  use  of  the  foot. 

Occasionally,  even  in  childhood,  one  may  encounter  marked 
limitation  of  normal  motion,  particularly  in  dorsal  flexion,  caused 
by  actual  shortening  of  the  muscles.  This  may  be  the  accommo- 
dative adaptation  characteristic  of  long-standing  deformity;  in 
other  instances  it  would  appear  to  be  the  result  of  a  slight  and 
unnoticed  neuritis  or  anterior  poHomyeUtis,  which  has  resulted  in 
muscular  inequality.  If  the  contraction  does  not  yield  readily 
to  manipulation  or  to  mechanical  stretching,  forcible  correction 
and,  if  necessary,  tenotomy  should  be  employed  in  the  manner 
already  described;  for  whatever  may  be  the  cause  it  is  ao-ain 
emphasized  that  obstruction  to  motion  in  every  direction  must 
be  overcome  before  a  complete  cure  is  possible. 

Adjuncts  in  Treatment. — It  must  be  apparent  that  in  many 
instances  the  anatomical  cure  of  the  weak  foot  is  impracticable, 
either  because  of  the  want  of  energy  or  opportunity  on  the  part 
of  the  patient,  or  because  of  the  local  or  general  conditions,  types 
familiar  in  out-patient  practice. 

The  Thomas  Treatment. — In  such  cases  raising  and  strengthening 
the  inner  side  of  the  shoe  by  the  wedge-shaped  leather  sole,  as 
used  by  Thomas,  splints  the  painful  foot  and  aids  in  relieving  the 
strain. 

Plaster  Strapping. — If  the  symptoms  are  more  acute  the  adhe- 
sive plaster  strapping,  as  advocated  by  Cottrell  and  Gibney 
for  the  treatment  of  sprains,  is  often  of  service,  although  it  is 


714  ORTHOPEDIC  SURGERY 

applied  in  a  different  manner,  and  with  a  different  object  in 
view.  One  end  of  a  strip  of  adhesive  plaster,  about  fifteen  inches 
long  and  three  inches  wide,  is  applied  to  the  outer  side  of  the 
ankle  just  below  the  external  malleolus;  the  foot  is  then  adducted 
as  far  as  possible,  and  the  band  is  drawn  tightly  beneath  the 
sole  up  the  inner  side  of  the  arch  and  leg,  and  is  stayed  in  this 
position  by  one  or  two  plaster  strips  about  the  calf  (Fig.  461). 
Narrow  plaster  straps  are  then  applied  about  the  arch  and  ankle, 
in  the  figure-of-eight  manner,  and  a  bandage  is  applied.  The 
object  of  the  dressing  is  to  aid  in  holding  the  foot  in  the  improved 
position  by  the  support  and  suggestiveness  of  the  plaster,  and  to 
provide  the  firm  compression  about  the  arch  that  is  always  agree- 
able to  the  sufferer  from  weak  foot.  This  treatment,  combined 
with  the  built-up  shoe,  is  often  very  effective  in  overcoming  the 
acute  and  disabling  symptonis  of  the  weak  and  injured  foot,  which 
are,  as  has  been  stated,  often  the  result  of  extra  strain  or  injury;  in 
other  words,  a  sprain  of  a  weak  foot.  Consequently,  when  these 
symptoms  are  relieved,  the  patient  who  has  become  habituated 
to  the  weakness  and  deformity  considers  himself  cured.  By  per- 
sistent manipulation  and  subsequent  support  with  the  adhesive 
plaster  one  may  overcome  the  deformity  in  the  majority  of  cases. 
When  this  is  accomplished  the  brace  is  applied  and  the  further 
treatment  that  has  been  described  is  continued.  Forcible  correc- 
tion under  anaesthesia  is,  however,  preferable  in  cases  of  the  more 
resistant  type. 

Operative  Treatment. — The  various  cutting  operations  for  the 
relief  of  flat-foot  do  not  call  for  extended  comment.  The  typical 
operation,  the  removal  of  a  wedge  from  the  astragalonavicular 
region,  aims  simply  at  removal  of  the  deformity.  It  should  be 
restricted  to  those  cases  in  which  the  adaptive  changes  are  so 
marked  that  functional  cure  is  impossible. 

The  operation  of  advancement  of  the  posterior  extremity  of  the 
OS  calcis,  as  proposed  by  Gleich,  in  order  that  it  may  be  placed 
in  relation  to  the  leg  somewhat  like  that  of  a  Pirogoft'  amputa- 
tion, offers  little  hope  of  ultimate  cure;  for  since  the  disability 
is  not  due  to  primary  depression  of  the  arch,  it  can  hardly  be 
cured  by  exaggerating  its  depth  in  this  manner.  Supramalleolar 
osteotomy,  in  which  the  bones  of  the  leg  are  divided  above  the 
ankle,  and  the  distal  extremity  turned  inward,  with  the  aim  of 
directing  the  weight  toward  the  outer  border  of  the  foot,  has  been 
advocated  by  Trendelenburg.  In  practice  the  operation  is  by  no 
means  always  successful,  while  the  bow-leg  deformity  that  results 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      715 

if  the  object  is  attained  is  an  unfortunate  accompaniment  of  the 
treatment.  It  may  be  mentioned  in  this  connection  that  fracture 
at  the  ankle-joint,  followed  by  faulty  union  in  a  position  of  valgus, 
is  a  form  of  traumatic  weak  foot  that  may  be  cured  by  this  opera- 
tion. In  operative  treatment  the  element  of  rest,  necessary  for 
weeks  or  months,  must  be  taken  into  consideration,  as  explaining 
in  part  the  immediate  favorable  effect  of  whatever  procedure  is 
adopted. 

In  conclusion,  the  following  points  are  again  emphasized: 
flat-foot  in  its  surgical  sense  is  a  compound  deformity,  in  which 
the  abnormal  relation  between  the  foot  and  the  leg,  causing  the 
improper  distribution  of  the  weight  and  the  strain  and  disuse  of 
normal  function,  is  of  vastly  greater  importance  than  the  depres- 
sion of  the  arch,  which  has  given  the  name  to  the  disability. 

The  weak  and  deformed  foot  can  be  cured,  but  only  by  the 
application  of  the  simple  principles  that  any  mechanic  would 
apply  to  a  disabled  machine  whose  structure  and  use  were  known 
to  him.  In  other  words,  there  can  be  no  permanent  cure  of  weak- 
ness and  deformity  unless  normal  function  is  regained,  or  effective 
treatment  unless  it  has  this  end  in  view. 

The  term  weak  foot  has  this  advantage  over  others  that  imply 
deformity,  in  that  it  may  be  properly  applied  to  the  earliest  in- 
dications of  disabiUty.  Once  weakness  is  recognized,  its  causes 
may  be  analyzed  and  appreciated  at  their  proper  value.  Flat-foot 
is  a  particularly  objectionable  and  misleading  term,  and  it  should 
be  discarded  or  at  least  used  only  to  describe  those  cases  to  which 
it  can  properly  be  applied. 


CHAPTER    XXI. 

DISABILITIES"  AND  DEFORMITIES  OF  THE  FOOT  (Continued). 
The  Hollow  or  Contracted  Foot. 

Synonyms,— Non-deforming  club-foot,  talipes  arcuatiis,  talipes 
plantaris,  talipes  cavus. 

The  depth  of  the  arch  and  the  corresponding  area  of  the  bear- 
ing surface  of  the  foot  vary  greatly  in  different  individuals,  and, 
although  marked  differences  in  contour  and  function  are  possible 
within  a  normal  range,  yet,  as  a  rule,  the  low  arch  is  character- 
ized by  relaxation  and  weakness  of  structure,  while  the  exaggerated 
arch  implies  a  corresponding  contraction  and  loss  of  normal 
elasticity. 

The  hollow  or  contracted  foot  may  be  divided  into  two  classes 
— the  primary  and  the  secondary.  In  the  first  class  the  simple 
exaggeration  of  the  arch  (talipes  arcuatus)  is  the  only  change 
from  the  normal  condition.  In  the  second  the  high  arch  is  com- 
bined with  limitation  of  the  range  of  dorsal  flexion  at  the  ankle- 
joint  (talipes  plantaris — Fisher). 

Etiology. — The  simple  hollow  foot  may  be  an  inherited  pecu- 
liarity. The  depth  of  the  arch  may  be  exaggerated  by  the  habitual 
use  of  high  heels  (postural  equinus),  or  by  excessive  use  of  the 
calf  muscles,  as  by  professional  dancers. 

The  secondary  variety,  in  which  the  hollow  foot  is  combined 
with  slight  equinus,  may  be  induced  by  habitual  use  of  high  heels, 
but  if  it  is  marked  its  origin  may  be  traced  in  many  instances  to 
a  mild  and  transient  form  of  anterior  poliomyelitis  or  neuritis 
in  early  childhood.  This  causes  temporary  weakness  of  the 
anterior  group  of  muscles  of  the  leg,  and  thus  a  slight  toe-drop, 
followed  by  secondary  contraction  of  the  tissues  of  the  sole  and 
of  the  muscles  of  the  calf.  In  the  history  of  many  of  these  patients 
it  will  appear  that  after  recovery  from  scarlatina  or  other  con- 
tagious or  infectious  disease  the  child  seemed  weak  or  awkward. 
These  symptoms  bec^ame  less  marked  or  practically  disappeared; 
yet  a  trace  remained,  although  not  of  sufficient  importance  to  call 
for  treatment,  until    adolescence  or  adult  fife,  when  the  greater 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      717 

strain  and  weight  put  upon  the  feet  brought  to  light  the  latent 
disability.  The  affection  may  undoubtedly  develop  in  later 
years  as  the  result  of  neuritis,  or  of  gout  or  rheumatism.  It  may 
be  caused  by  a  sprain  or  fracture  of  the  ankle,  and  it  may  be  a 
result  of  habitiud  posture  in  compensation  for  a  limb  shortened  by 
injury  or  disease. 

The  exaggerated  arch  which  is  a  part  of  a  more  important 
deformity,  as  of  equinovarus  or  calcaneus,  or  that  which  is  simply 
one  of  many  distortions  caused  by  diseases  of  the  nervous  appa- 
ratus, does  not  belong  to  the  class  of  disability  under  consideration. 

Fig.   462 


The  contracted  foot  of  slight  degree. 

Symptoms. — The  simple  hollow  foot  often  exists  without 
symptoms;  in  fact,  it  is  usually  considered  as  a  particularly  well- 
formed  foot  rather  than  a  deformity.  The  common  complaint  in 
these  cases  is  that  one  is  unable  to  buy  comfortable  shoes  because 
the  ordinary  shoe  does  not  support  the  arch,  or  because  the 
leather  presses  on  the  dorsum  of  the  foot.  The  convexity  of  the 
dorsum,  of  course,  corresponds  to  the  depth  of  the  arch;  in  many 
instances  the  cuneiform  bones  project  sharply  beneath  the  skin, 
and  painful  pressure  points  or  even  inflamed  bursjv  in  this  locality 
may  cause  discomfoit. 


718 


ORTHOPEDIC  SURGERY 


In  the  well-marked  cases  in  which  the  weight  is  borne  entirely 
on  the  heel  and  the  front  of  the  foot,  calluses  and  corns  usually 
form  at  the  centre  of  the  heel  and  beneath  the  heads  of  the 
metatarsal  bones.  The  patient  may  complain  of  neuralgic  pain 
about  the  great  toe,  the  metatarsal  arch,  or  in  the  sole  of  the  foot. 
The  gait  is  often  ungraceful,  as  the  patient  walks  heavily  upon 
the  heels  with  the  feet  turned  outward.  In  such  cases  "the 
ankles  may  be  weak  and  turn  easily."  In  the  more  advanced 
cases  of  this  type  the  foot  may  assume  the  position  of  valgus 

Fig.   463 


Contracted  foot,  marked. 

when  weight  is  borne,  so  that  the  more  noticeable  symptoms  are 
those  of  the  weak  foot  or  so-called  flat-foot. 

Contracted  foot,  of  the  more  severe  grade,  is  almost  always 
accompanied  by  a  certain  limitation  of  dorsal  flexion;  and  as  the 
shortening  of  the  plantar  fascia  is  often  more  marked  at  its  inner 
border,  a  slight  inversion  of  the  forefoot  or  varus  may  be  present 
also. 

When  the  exaggerated  arch  is  combined  with  limitation  of 
dorsal  flexion  the  deformity  is  usually  greater.  This  limitation 
may  be  very  slight,  or  it  may  be  well-marked;  and  a  slight  degree 
of  permanent  equinus  even  may  be  present,  but  so  slight  that  it 
does  not,  as  a  rule,  attract  attention. 

This  type  of  the  contracted  foot  was  first  clearly  described  by 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     719 

■Shaffer,  in  1885,  under  the  title  of  "non-deforming  ckib-foot,"^ 
and  later  by  Fisher,  of  London,  as  "taUpes  plantaris." 

The  symptoms  are  similar  to  those  of  the  simple  hollow  foot, 
but  they  are  almost  always  more  marked.  The  gait  is  awkward 
and  jarring,  the  feet  being  turned  outward  to  an  exaggerated 
degree.  The  patient  is  easily  fatigued,  and  often  complains  of  the 
weakness  about  the  ankle  and  inner  side  of  the  arch,  characteristic 
of  the  weak  foot,  and  of  sensations  of  tire  and  strain  in  the  calf 
of  the  leg.  The  discomfort  from  corns,  the  pain  referred  to  the 
metatarsal  region,  the  great  toe,  and  to  the  sole  of  the  foot  have 
been  described  already. 

On  examination  the  exaggeration  of  the  arch  is  evident,  and 
an  imprint  of  the  sole  shows  that  the  weight  is  borne  entirely  on 
the  heel  and  on  the  heads  of  the  metatarsal  bones,  which  may  be 
very  prominent  beneath  the  thickened  skin,  as  if  the  subcuta- 
neous fat  had  been  absorbed.  The  anterior  metatarsal  arch  is 
often  obliterated,  and  the  toes  are  usually  habitually  dorsiflexed 
at  the  first  phalanges,  the  permanent  flexion,  with  the  resulting 
pressure  against  the  leather  of  the  shoe  being  indicated  by  a  row 
of  corns  upon  their  dorsal  surfaces  (Fig.  463). 

The  contracted  plantar  fascia  may  be  demonstrated  by  forcible 
dorsal  flexion  of  the  foot,  when  the  tense  bands,  in  many  instances 
very  sensitive  to  pressure,  may  be  felt  beneath  the  skin. 

On  testing  the  movements  of  the  foot,  the  limitation  of  dorsal 
flexion,  both  of  the  voluntary  and  the  passive  range,  will  be  evi- 
dent. In  voluntary  flexion  the  toes  are  drawn  up  and  the  tendons 
are  plainly  seen  on  the  dorsum,  showing  the  effort  made  by  the 
accessory  muscles  to  overcome  the  abnormal  resistance. 

The  limitation  of  dorsal  flexion  may  be  demonstrated  in  the 
manner  suggested  by  Shaffer,  by  asking  the  patient  to  flex  the 
feet  while  standing  erect  with  the  back  to  the  wall,  when,  in  spite 
of  the  effort  made,  "the  feet  remain  glued  to  the  floor." 

Treatment. — In  the  ordinary  form  of  contracted  foot,  as  has 
been  stated,  the  disability  is  much  more  marked  than  the  defor- 
mity; and  the  disability  is  due  to  secondaiy  changes  in  the  struc- 
ture of  the  foot,  by  which  its  elasticity  is  impaired.  If  this  can 
be  restored  in  some  degree  permanent  relief  will  follow.  If  the 
simple  hollow  foot  (cavus),  or  the  secondary  type  (plantaris), 
were  discovered  in  early  childhood,  massage  and  methodical 
stretching  would,  in  all  probability,  be  sufficient  to  relieve  the 
contractions;  but,  as  a  rule,  no  symptoms  are  noticed  until  later 

1  New  York  Medical  Record,  May  23,  1885. 


720  ORTHOPEDIC  SURGERY 

life.  Even  then,  especially  in  the  simple  form,  they  are  often 
slight  and  may  be  reheved  by  a  shoe  with  a  broad  heel  and  a  high 
(Spanish)  arch  or  by  a  foot-plate  that  eqiiahzes  the  pressure  on 
the  sole. 

In  the  more  advanced  cases  of  the  milder  type  methodical 
forcible  manual  stretching  may  elongate  the  tissues  sufficiently 
to  reheve  the  symptoms.  The  Shaffer^  "traction  shoe"  may  be 
used  with  advantage  for  the  same  purpose.  In  the  more  resist- 
ant cases,  however,  di\dsion  of  the  contracted  parts  and  forcible 
correction  of  deformity  are  indicated. 

Operative  Treatment. — The  patient  having  been  ancesthetized, 
a  tenotomy  knife  is  introduced  beneath  the  skin  to  the  inner  side 
of  the  central  band  of  fascia.  This  is  di^dded  by  a  sawing  motion, 
and  if  on  forced  dorsal  flexion  other  tense  bands  appear  they 
are  divided  also.  Forcible  massage,  with  the  aim  of  making 
the  foot  flexible  and  reducing  the  depth  of  the  arch,  is  then 
employed.  If  more  force  is  required  the  Thomas  wrench 
may  be  used  as  in  the  treatment  of  club-foot;  the  object 
being  to  elongate  the  foot,  to  remove  the  contraction,  and 
thus  by  increasing  the  area  of  bearing  surface  to  relieve  the 
painful  pressure  on  the  heads  of  the  metatarsal  bones.  If  the 
contraction  of  the  tendo  Achillis  cannot  be  overcome  by  forcible 
manipulation  it  may  be  divided.  The  foot  is  then  fixed  in  a 
well-fitting  plaster  bandage  in  an  attitude  of  dorsal  flexion,  a 
thin  board,  shaped  to  the  foot,  having  been  incorporated  in  the 
bandage,  in  order  that  firm  and  even  pressure  may  be  exerted 
upon  the  sole.  As  soon  as  possible,  often  on  the  following  day, 
the  patient  is  encouraged  to  walk  about,  in  order  that  the  pressure 
of  the  body  weight  may  be  utilized  to  flatten  the  foot  still  more, 
while  its  tissues  are  in  a  yielding  condition. 

The  bandage  may  be  continued  for  six  weeks,  or,  if  the  tendo 
Achillis  has  been  divided,  until  its  repair  is  complete.  A  well- 
fitting  shoe  should  be  wor/i,  and  methodical  massage  and  stretching 
of  the  tissues  should  be  continued  as  long  as  the  tendency  to 
deformity  remains. 

By  this  treatment  the  symptoms  may  be  relieved,  and  in 
many  instances  a  return  to  the  normal  shape  and  function  can 
be  assured. 

'  New  York  Medical  Journal,  March  5,  1887.  ! 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     721 

Weakness  of  the  Anterior  Metatarsal  Arch. 

Anterior  Metatarsalgia  and  Morton's  Neuralgia. — A  peculiar 

spasmodic  pain  about  the  fourth  toe  was  described  by  Morton, 
of  Philadelphia,  long  before  its  predisposing  and  exciting  causes 
were  understood.  For  this  reason  a  description  of  the  symptoms 
may  with  advantage  precede  a  consideration  of  the  weakness  of 
which  they  are  usually  the  result. 

Typical  cases  of  Morton's^  painful  affection  of  the  foot  are 
characterized  by  a  sudden  cramp-like  pain  in  the  region  of  the 
fourth  metatarsophalangeal  articulation. 

The  pain  may  begin  as  a  burning  sensation  beneath  the  toe,  as 
a  numb  or  tingling  feeling,  as  a  sudden  cramp,  or  as  a  peculiar 
feeling  of  discomfort  about  the  articulation  that  increases  in 
severity  until  it  becomes  almost  unbearable.  At  first  the  pain  is 
confined  to  the  neighborhood  of  the  affected  joint,  but  unless  it 
is  relieved  it  radiates  to  the  extremity  of  the  toe,  to  the  dorsum 
of  the  foot,  or  up  the  leg.  In  many  instances  the  onset  of  the 
pain  is  preceded  by  the  sensation  of  something  moving  or  slipping 
in  the  foot;  in  some  cases  the  pain  may  be  induced  by  sudden 
movements,  missteps,  or  by  long  standing,  and  in  practically  all 
the  cases  the  pain  is  felt  only  when  the  shoes  are  worn.  The 
frequency  of  the  recurrent  cramp  varies;  in  some  cases  it  appears 
only  at  infrequent  intervals;  in  others  it  practically  disables  the 
patient.  When  the  "cramp"  habit  has  been  acquired,  \tT\  slight 
causes  may  induce  the  pain — for  example,  a  thin-soled  shoe,  a  hot 
pavement,  "the  sticking  of  the  sock  to  the  foot,"  and  the  like — - 
but,  as  has  been  stated,  except  in  the  very  advanced  and  chronic 
cases,  the  pain  is  never  felt  except  when  the  shoe  is  worn. 

To  relieve  the  pain  the  patient  removes  the  shoe,  rubs  and 
compresses  the  front  of  the  foot,  flexes  and  extends  the  toes,  and 
the  like.  After  the  cramp  is  relieved  a  sensation  of  soreness 
remains,  and  occasionally  slight  swelling  may  appear,  but  in 
most  instances  there  are  no  external  signs,  although  the  affected 
articulation  is  usually  sensitive  to  deep  pressure  at  all  times. 

The  more  comprehensive  term,  anterior  meta tarsalgia,  a  term 
suggested  by  Poulosson,  of  Lyons,  in  1889,  may  be  employed  to 
include  Morton's  neuralgia,  and  similar  symptoms  of  pain  and 
discomfort  about  the  anterior  metatarsal  arch.  For  in  many 
instances  the  cramp-like  pain   is   referred   to   other  points,  for 

•  T.  G.  Morton,  American  Journal  of  the  Medical  Sciences,  August,  1876. 

46 


722  ORTHOPEDIC  SURGERY 

example,  to  several  adjoining  joints,  or  the  discomfort  caused 
apparently  by  direct  pressure  on  the  bones  of  the  weakened  arch 
may  be  more  disabhng  than  the  irregular  attacks  of  neuralgic 
pain  characteristic  of  Morton's  ajffection. 

Etiology  and  Pathology. — In  7S  cases  of  anterior  metatarsalgia 
in  which  the  location  of  the  pain  was  noted,  it  was  referred  to 
the  fourth  metatarsophalangeal  articulation  in  60;  to  the  third  and 
fourth  articulation  in  6;  to  the  second,  third,  and  fourth  in  6, 
and  in  but  6  was  the  fourth  articulation  free  from  pain.  The 
pain  is  most  often  unilateral,  or,  if  the  second  foot  is  affected,  it 
is  usually  after  a  considerable  interval. 

The  affection  is  more  common  in  females  than  in  males.  Of 
84  cases,  64  were  in  women  and  20  were  in  men. 

Anterior  metatarsalgia  is  not  an  affection  of  early  life,  the 
average  age  in  the  reported  cases  being  more  than  thirty  years. 
It  is  far  more  common  in  private  than  in  hospital  practice,  and 
not  infrequently  the  patients  are  of  a  distinctly  nervous  type. 
In  many  instances  it  is  supposed  to  be  a  family  inheritance.  The 
affection  is  usually  extremely  chronic.  Occasionally  the  symp- 
toms may  cease  spontaneously,  and  in  such  instances  a  particular 
pattern  of  shoe  usually  receives  the  credit  of  the  cure. 

]\Iorton  considered  the  disability  to  be  a  painful  affection  of  the 
plantar  nerves  due  to  compression  or  pinching  by  the  adjoining 
fourth  and  fifth  metatarsophalangeal  articulations.  This  com- 
pression was  explained  by  the  anatomical  construction  of  the  foot — 
i.  e.,  the  mobility  of  the  fifth  metatarsal  bone  which  allowed  it 
to  roll  above  and  under  the  fourth,  its  relative  shortness  which 
allowed  the  head  and  base  of  the  adjoining  phalanx  to  be  brought 
against  the  adjoining  head  and  neck  of  the  fourth  bone,  and, 
finally,  by  the  peculiar  distribution  of  the  external  plantar  nerve 
between  these  bones  that  made  it  or  its  fibres  more  liable  to  injury. 
This  natural  mobility  and  thus  the  predisposition  to  compres- 
sion might  be  exaggerated  by  a  sprain,  or  possibly  by  rupture  of 
the  transverse  metatarsal  ligament,  or  the  pain  might  be  induced 
by  wearing  tight  shoes,  but  in  many  instances  no  cause  could  be 
assigned.  On  this  theory  Morton  advocated  excision  of  the 
head  of  the  fourth  metatarsal  bone  to  remove  the  point  of  counter- 
pressure.  This  operation  has  been  performed  many  times,  but 
practically  no  pathological  changes  in  the  resected  bone  or  in 
the  surrounding  parts  have  ever  been  discovered. 

In  more  recent  years  the  true  significance  of  Morton's  neuralgia 
and  of  similar  pains  in  the  front  of  the  foot  has  been  made  more 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      723 

clear  by  the  study  of  the  relation  of  weakness  of  the  anterior 
transverse  metatarsal  arch  to  the  symptoms.  Attention  was 
first  called  to  this  point  by  Poulosson,  and  again  by  Roughton, 
Woodruff,  and  others,  and  in  a  much  more  thorough  and  con- 
vincing manner  by  Goldthwait/  in  1894. 

The  Anterior  Metatarsal  Arch. — In  the  normal  foot  the  two 
central  metatarsal  bones,  the  second  and  third,  are  slightly  longer 
and  on  a  higher  plane  than  their  fellow^s.  On  the  sole  of  the  foot 
the  arch  is  shown  by  the  depression  on  the  outer  side  of  the 
muscular  projection  of  the  great  toe-joint.  When  weight  is  borne 
all  the  metatarsal  bones  are  on  the  same  plane  and  the  arch  is 
obliterated,  but  when  the  weight  is  removed  the  arch  is  restored 
by  certain  natural  resiliency.  In  walking  and  standing  the  weight 
falls  in  the  neighborhood  of  the  head  of  the  third  metatarsal 
bone,  as  shown  by  a  thickening  of  the  skin  beneath  it,  but 
the  strain  on  the  metatarsal  arch  is  reUeved  somewhat  by 
the  balancing  action  of  the  muscles  about  the  first  and  fifth  meta- 
tarsal bones,  the  inner  and  outer  supports  of  the  arch,  and  by 
the  active  assistance  of  the  toes  themselves.  When  the  arch  is 
weak  or  broken  down  this  natural  resiliency  is  lost,  and,  in  some 
instances,  the  centre  of  the  forefoot  is  not  only  depressed  but  it  is 
fixed  in  this  abnormal  attitude. 

In  the  ordinary  type  of  depressed  anterior  arch  the  deformity 
may  be  shown  by  an  imprint  of  the  foot,  in  which  the  flabby 
tissues  of  the  depressed  arch  encroach  upon  the  clear  space  repre- 
senting the  longitudinal  arch,  and  obliterate  what  Goldthwait 
calls  the  re-entering  angle  to  the  outer  side  of  the  great  toe-joint, 
which  in  the  normal  foot  indicates  the  highest  point  of  the 
metatarsal  arch.  In  many  instances,  however,  the  imprint  of  the 
foot  subject  to  Morton's  neuralgia  may  be  to  all  intents  normal, 
and,  on  the  other  hand,  depression  of  the  metatarsal  arch,  one  of 
the  very  common  results  of  improper  shoes,  may  be  present,  yet 
unaccompanied  by  pain  or  discomfort. 

Depression  of  the  anterior  arch  predisposes  to  pain  because 
of  abnormal  pressure  upon  the  persistently  depressed  articula- 
tions from  beneath,  and  it  predisposes  to  pain,  as  the  writer 
has  endeavored^  to  explain,  because  the  metatarsophalangeal  joints 
of  an  habitually  depressed  arch  are  exposed  to  the  (Hrect  lateral 
compression  of  a  narrow  or  ill-shaped  shoe. 

This   point   may   be   illustrated    in   the   hand.     When    lateral 

'  Boston  Medical  and  Surgical  Journal,  vol.  cxxxi.  p.  233. 
-  New  York  Medical  Record,  August  6,  1898. 


724  OB  THOPEDIC  S UB GEB  Y 

pressure  is  applied,  the  hand  is  folded  together  and  the  anterior 
metacarpal  arch  is  increased  in  depth,  but  if  the  fingers  are  dorsi- 
flexed  so  that  it  is  fixed  in  a  depressed  position,  then  lateral 
compression  causes  great  pain  at  all  the  articulations  (Fig.  464); 
or  if  one  finger  is  dorsiflexed  and  the  corresponding  metacarpal 
bone  is  thus  forced  below  the  level  of  its  fellows,  lateral  compres- 
sion causes  pain  at  the  compressed  joint.  Or  if  the  metacarpal 
bone  of  the  httle  finger  is  made  to  over-ride  the  fourth,  lateral 
pressure  causes  pain  usually  of  a  more  acute  character  than  at 
the  other  joints,  because  the  opportunity  for  direct  pressure  is 
more  favorable.^  Finally,  if  firm  pressure  is  made  upon  one  or 
the  other  side  of  the  head  of  the  depressed  metacarpal  bone  of  the 

Fig.  464 


Position  of  the  fingers  corresponding  to  dorsiflexion  of  the  toes,  an  attitude  in 
which  lateral  pressure  causes  pain. 

dorsiflexed  finger  in  the  palm  of  the  hand,  a  point  of  sensitive- 
ness, representing  apparently  the  digital  nerve,  can  be  made  out. 
The  same  experiments  may  be  tried  upon  the  foot  with  the  same 
results,  and  it  would  seen  to  make  clear  the  mechanism  of  the 
pain  of  Morton's  neuralgia  and  the  allied  forms  of  discomfort  at 
the  front  of  the  foot. 

Anterior  metatarsalgia  is  in  most  instances  the  result  of  weak- 
ness or  depression  of  the  anterior  metatarsal  arch  as  a  whole  or  in 
part,  and  the  quality  of  the  pain  corresponds  fairly  to  the  form 
of  weakness  or  deformity.  If,  for  example,  the  entire  arch 
is  rigidly  depressed,  as  in  certain  rheumatic  affections,  the 
discomfort  is  likely  to  be  caused,  in  great  degree,  by  the  direct 

*  This  anatomical  peculiarity  is  well  known  to  school-boys. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     725 

pressure  of  the  sensitive  depressed  metatarsophalangeal  joints  on 
the  sole  of  the  shoe;  or,  if  lateral  pressure  is  exerted  as  well,  the 
discomfort  or  pain  may  be  referred  to  the  metatarsal  arch  in 
general.     If  the  metatarsal  arch   is   weakened,   depressed,   and 
broadened,  but  not  rigid,  the  discomfort  is  often  referred,  as  in 
the  preceding  instance,  to  the  centre  of  the  arch,  and  this  dis- 
comfort is  increased,  in  some  instances,  by  a  painful  callus  repre- 
senting abnormal  pressure  at  this  point.     If  one  of  the  metatarsal 
bones  falls  below  its  fellows,  the  lateral  pressure  of  a  narrow 
shoe  may  cause  neuralgic  pain  at  this  joint,  but  in  many  cases 
in  which  the  anterior  arch  is  depressed  the  patient  makes  but 
little  complaint  of  pain.     In  certain  instances,  more  particularly 
those  of  Morton's  typical  neuralgia,  the  foot  may  appear  to  all 
intents  normal;  in  such  cases  it  may  be  inferred  that  the  sharp 
and  characteristic  pain  is  caused  by  pressure  applied  to  the  over- 
riding fifth  metatarsal  bone,  just  as  similar  pain  is  felt  if  tlie  hand 
is  suddenly  compressed  while  the  fifth  metacarpal  bone  is  in  the 
same  position.     This  theory  is  the  more  probable  when  one  con- 
siders the  symptoms;   for  example,  the  sensation  of   something 
slipping  or  moving,  the  necessity  for  the  removal  of  the  shoe  to 
flex  and  extend  the  toes  and  to  compress  the  foot,  apparently 
with  the  instinctive  aim  of  replacing  a  depressed  arch,  or  a  mis- 
placed bone  in  the  arch.     It  would  also  explain  how  the  shoe 
may  be  the  most  direct  of  the  exciting  causes  of  the  deformity, 
in  that  it  compresses  the  forefoot  and  throws  more  weight  upon 
it  by  elevating  the  heel.     If  the  arch  is  depressed  or  becomes 
depressed,  or  if  a  bone  in  the  arch  overrides  another,  this  compres- 
sion causes  the  symptoms. 

That  classical  Morton's  neuralgia  is  but  one  expression  of 
weakness  of  the  anterior  arch  of  the  foot  is  illustrated  by  an 
analysis  of  30  cases  seen  recently  in  private  practice: 

Cases. 

The  pain  was  referred  to  the  fourth  toe  in 12 

"  "        third  and  fourth  toes  in 4 

"  "       second,  third,  and  fourth  toes  in       .      .      2 

"  "  "       third  toe  in .3 

"        second  and  third  toes  in 2 

'        second  toe  in 6 

to  all  the  toes  iu 1 

The  right  foot  was  involved  in .13 

The  left  "  " 7 

Both  feet  were  affected  in 8 

Twenty-four  of  the  patients  were  females;  four  were  males. 

The  Influence  of  the  Shoe  in  Causing  Disability  and  Pain.— 
In  the  etiology  of  pain  and  discomfort  about  the  anterior  nixh  one 
must  recognize  the  shoe  not  only  as  the  direct  cause  of  the  pain, 


726  OETHOPEDIC  SURGERY. 

but  also  as  the  most  important  of  the  predisposing  causes  of 
weakness  of  the  anterior  arch,  of  which  the  pain  is  a  symptom, 
since  it  compresses  the  toes,  lifts  them  off  the  ground  by  its  "rocker 
sole,"  and  thus,  by  preventing  their  normal  function,  throws 
additional  strain  and  pressure  upon  the  arch.  In  fact,  in  a  very 
large  proportion  of  feet  that  are  supposed  to  be  normal  in  appear- 
ance and  functional  ability,  the  toes  are  habitually  dorsiflexed 
in  a  claw-like  attitude,  that  shows  entire  disuse  of  their  function 
both  as  to  support  and  progression.  Women  wear  shoes  with 
narrower  soles  and  higher  heels  than  men,  and  this  seems  the 
most  reasonable  explanation  of  the  fact  that  they  are  more  sub- 
ject to  the  affection. 

The  shoe  also  predisposes  to  habitual  elevation  of  the  fifth 
metatarsal  bone,  because  this  bone  almost  invariably  overhangs 
the  narrow  sole.  The  fourth  metatarsal  bone  becomes,  therefore, 
the  outer  support  of  the  arch,  and  is  almost  always  found  to  be 
on  a  lower  level  than  the  adjoining  bones.  This  relation,  together 
with  a  laxity  of  muscular  and  ligamentous  support  induced  by 
injury  or  otherwise,  may  account  for  the  location  of  the  pain  at 
this  point  in  the  majority  of  cases.  Although  in  certain  instances 
local  neuritis  may  result  from  repeated  injury,  it  is  a  rather  unusual 
complication.  Nor  is  it  likely  that  the  peculiar  distribution  of  the 
nerves  at  the  fourth  joint  has  any  direct  influence  on  the  location 
of  the  pain,  for  the  nerve  supply  of  all  the  joints  and  all  the 
toes  is  practically  identical. 

Other  Factors  in  the  Etiology. — Besides  the  general  effect  of  the 
shoe,  and  the  influence  of  an  inherited  predisposition  to  the 
affection,  which  seems  evident  in  certain  cases,  or  of  weakness 
or  direct  injuiy  of  the  anterior  arch,  one  recognizes  among 
the  causes  or  complications  of  anterior  metatarsalgia  weak- 
ness of  the  longitudinal  arch,  which  may  be  combined  with  a 
depression  of  the  anterior  arch.  Less  often  the  longitudinal 
arch  may  be  exaggerated  in  depth  and  the  dorsal  flexion  of  the 
foot  may  be  limited  by  a  shortened  tendo  Achillis;  thus  more 
pressure  is  brought  upon  the  front  of  the  foot.  In  these  cases 
the  pain  may  be  increased  by  corns  or  calloused  skin  beneath  the 
depressed  bones,  and  in  many  instances  the  discomfort  of  the 
depressed  arch  of  the  ordinary  type  is,  in  great  part,  caused  by 
a  sensitive  com  or  fibroma  at  the  point  of  greatest  depression, 
and  the  patient  may  be  entirely  relieved  by  its  removal.  (See 
Contracted  Foot.) 

Although   the   symptoms   of   anterior   metatarsalgia   may   be 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     727 


Fig.  465 


explained  in  most  instances  by  the  primary  effect  of  improper 
shoes,  by  weakness  and  abnormality  of  the  foot  itself,  and  by  the 
local  sensitiveness  of  the  parts  that  are  continually  subjected  to 
strain,  pressure,  and  injury,  yet  in  some  instances  the  symptoms 
can  be  accounted  for  only  by  local  neuritis;  in  others  they  are 
aggravated  by  gout  or  rheumatism  or  general  debility,  and,  as 
has  been  mentioned  in  a  large  proportion  of  the  cases,  the  patients 
are  of  a  distinctly  nervous  type. 

It  may  be  stated,  in  conclusion,  that  anterior  metatarsalgia  in 
its  milder  forms  is  a  very  common  affection,  and  one  rarely  treats 
a  patient  who  does  not  know  of  other  cases  similar  to  his  own. 

Treatment. — The  most  important  local  treatment  is  to  pro\ide 
the  patient  with  a  suitable  shoe.  This  shoe  must  be  of  proper 
shape  with  a  thick  sole,  so  broad  that  no 
lateral  compression  of  the  toes  is  possible, 
with  a  high  arch,  as  suggested  by  Gibney, 
in  order  to  remove  a  part  of  the  pressure 
from  the  heads  of  the  metatarsal  bones, 
and  a  low  heel. 

As  an  immediate  treatment  a  firm  bandage 
about  the  metatarsal  region,  as  suggested  by 
Morton,  may  aid  in  supporting  the  meta- 
tarsal arch,  or,  better,  adhesive  plaster  strap- 
ping may  be  applied  about  the  entire  meta- 
tarsus, with  the  object  of  compressing  the 
foot  somewhat  as  a  tight  glove  compresses 
the  hand.  Beneath  or  slightly  behind  the 
affected  joint  or  the  depressed  arch,  a  pad, 
preferably  an  oval  piece  of  sole-leather,  about 
one  inch  by  three-quarters  of  an  inch  in  size 
and  one-quarter  in  thickness,  with  bevelled 
edges,  may  be  fixed  to  the  sole  of  the  foot 
with  adhesive  plaster,  so  that  depression  of 
the  arch  or  over-riding  of  the  adjoining 
bones  may  be  prevented.  This  pad,  sug- 
gested by  Poulosson  and  Goldthwait,  usually  reUeves  the  pain, 
and  when  the  exact  place  has  been  ascertained  it  may  be  fixed 
to  the  sole  of  the  shoe. 

As  a  rule,  however,  a  metal  support  will  be  found  to  be  more 
comfortable  and  far  more  efficient.  This  may  be  constructed  of 
light  steel  (19  gauge)  upon  a  plaster  cast  of  the  sole  of  the  foot, 
of  which  the  natural  depressions,  indicating  the  anterior  and  th? 


A  brace  for  anterior  meta 
tarsalgia.  A  indicates  a 
point  beneath  the  fourth 
metatarsophalangeal  artic- 
ulation, which  is  elevated 
in  order  to  support  the  de- 
pressed articulation. 


728 


ORTHOPEDIC  SURGERY 


longitudinal  arches,  have  been  somewhat  exaggerated.  The 
anterior  extremity  of  the  brace  is  made  as  wide  as  the  foot,  and 
extends  forward  slightly  beyond  the  metatarsophalangeal  articu- 
lations. The  brace  serves  to  support  the  anterior  as  well  as  the 
longitudinal  arch.  In  certain  instances  one  or  more  of  the 
metatarsophalangeal  articulations  may  be  sensitive  to  motion. 
In  such  cases  the  plate  must  extend  from  the  heel  to  the 
extremity  of  the  sole  in  order  to  spHnt  the  foot  for  a  time.  If 
there  is  slight  depression  of  the  longitudinal  arch  it  may  be 
further  corrected  bv  raising  the  inner  border  of  the  heel  and 
sole  of  the  shoe;  but  if  it  is  more  pronounced  a  flat-foot  brace 
(Fig.  453)  may  be  employed,  whose  anterior  extremity  is  modified 
to  support  the  metatarsal  arch,- as  is  shown  in  Fig.  465.     If,  on  the 

Fig.   466 


Exercise  for  the  weakened  metataisal  arch. 


other  hand,  the  arch  is  exaggerated  and  if  dorsal  flexion  is  limited, 
treatment  with  the  aim  of  relieving  this  deformity  will  be  necessary, 
as  described  under  "contracted  foot."  When  the  immediate 
symptoms  of  pain  and  local  discomfort  have  been  relieved,  the 
patient  must  endeavor  to  strengthen  the  natural  supports  of  the 
arch  by  proper  functional  use  of  the  foot,  and  by  regular  exercises 
of  the  muscles,  more  especially  by  methodical  forced  flexion 
of  the  toes,  as  this  motion  elevates  the  anterior  metatarsal  arch 
(Fig.  466).  Massage  of  the  foot  and  forcible  manipulation  of 
the  toes  for  the  purpose  of  overcoming  restriction  of  motion  are 
of  special  value. 

If  the  depressed  anterior  arch  is  rigid,  as  in  some  instances, 
its  flexibility  must  be  restored  by  manipulation  or  by  forcible 
correction  under  anaesthesia  before  a  brace  can  be  applied.     If 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      729 

the  symptoms  are  very  acute,  and  particularly  if  they  have  fol- 
lowed direct  injury,  the  parts  should  be  placed  at  rest  and  the 
anterior  arch  should  be  elevated  and  supported  by  a  properly 
applied  plaster  bandage. 

In  chronic  and  resistant  cases  or  when  conservative  treatment 
cannot  be  applied,  resection  of  the  neck  and  head  of  the  meta- 
tarsal bone  at  the  seat  of  pain  may  be  performed  as  advocated  by 
Morton.  The  operation  is  very  simple.  An  incision  is  made 
over  the  dorsal  surface  of  the  joint,  and  the  bone  is  divided  by 
bone  forceps.  The  toe  is  not,  as  a  rule,  removed,  but  after  the 
operation  it  slowly  recedes  between  the  adjoining  metatarso- 
phalangeal joints,  causing  a  rather  noticeable  deformity.  The 
operation  is,  as  a  rule,  successful,  but  in  the  majority  of  cases  it 
is  unnecessary. 

The  general  condition  of  the  patient  should,  of  course,  receive 
attention,  and  local  applications,  electricity,  and  the  like,  may 
be  of  benefit  in  special  cases. 

A  sensitive  callus  beneath  the  arch  may  require  treatment,  and  in 
certain  cases  its  removal  may  be  the  only  treatment  required  other 
than  an  improved  shoe.  But,  as  a  rule,  the  cause  of  the  callus 
is  habitual  depression  of  one  or  more  of  the  metatarsophalangeal 
articulations,  so  that  cure  can  only  be  assured  by  supporting 
the  arch  and  by  strengthening  its  natural  supports.  If  as  in  cer- 
tain instances  the  depressed  joint  cannot  be  replaced  in  normal 
position  the  head  of  the  metatarsal  bone  must  be  removed. 

Woodruff^  described  a  case  of  what  he  called  "incomplete  luxa- 
tion of  the  metatarsophalangeal  articulation,"  in  which  the  symp- 
toms, practically  identical  with  those  of  INIorton's  neuralgia, 
are  ascribed  to  an  upward  displacement  of  the  proximal  phalanx 
at  the  fourth  metatarsophalangeal  joint. 

It  may  be  stated  in  this  connection  that  in  the  ordinary  forms  of 
metatarsalgia  patients  often  refer  the  pain  and  local  sensitiveness 
to  the  anterior  extremity  of  the  metatarsal  bone  rather  than  to  its 
lateral  aspect.  Persistent  dorsal  flexion  of  the  toes  that  is  so 
commonly  associated  with  depression  of  the  arch  may  strain  the 
capsular  ligament,  and,  subjecting  this  portion  of  the  joint  to 
abnormal  pressure,  may  explain  the  location  of  the  pain.  But 
except  in  extreme  cases  it  can  hardly  be  classed  as  a  sublux- 
ation. 

Another  writer,  Guthrie,^  described  a  case  in  which   intense 

1  New  York  Medical  Record,  January  IS,  1887. 
-  Lancet.  March  19,  1892. 


730  ORTHOPEDIC  SUBGEBY 

pain  followed  overextension  of  the  third  phalanx  upon  the  second. 
Such  cases  are  extremely  uncommon,  and  need  only  be  mentioned. 

Achillobursitis. 

Synonyms.  —  AchillodjTiia,     achillobursitis     anterior,     retro- 
calcaneobursitis. 

Under  the  title  of  Achillodynia,  Albert,^  in  1893,  called  par- 
ticular attention  to  an  affection  characterized  by  pain  and  sen- 
sitiveness about  the  insertion  of  the  tendo  AchilHs,  symptoms 
usually  caused  by  irritation  or  inflammation  of  the  small  bursa 
Mng  between  the  insertion  of  the  tendon  and  the  bone  (Fig.  467). 
Etiology. — In  the  acute  cases  the  cause  of  the  bursitis  often 
appears  to  be  a  strain  of  the  tendon  or  direct  injury,  as  the  symp- 
toms appear  immediately  after  running  or  jumping  or  after  a 
fall,  sometimes  after  a  long  walk  or  bicycle  ride. 

In  the  subacute  cases  the  symptoms  may  begin  almost  imper- 
ceptibly, so  that  it  may  be  impossible  to  assign  a  direct  cause 
other  than  the  pressure  of  the  shoe,  aggra- 
FiG.  467  vated,  it  may  be,  by  an  exostosis  of  the  os 

calcis  beneath  the  insertion  of  the  tendon 
or  by  concretions  within  the  bursa.  In 
many  instances  rheumatism,  gout,  gonor- 
rhoea, or  one  of  the  infectious  diseases 
appear  to  be  associated,  directly  or  in- 
directly, with  the  onset  of  the  symptoms, 
or  the  bursa  may  be  secondarily  involved 
in  tuberculous  disease  of  the  os  calcis. 

Symptoms. — In   a   typical  case  pain  is 
felt  in  the  back  of  the  heel  at  the  insertion 
Bursa  between  the  tendo     qJ  ^\^q  tcudou;  the  pain  is  increased  by  use 

Acmllis  and  the  os  calcis.  '■^  ^ 

of  the  foot,  and  particularly  by  the  attitudes 
in  which  the  strain  on  the  part  is  increased,  as,  for  example,  in 
descending  stairs.  There  is  also  sensitiveness  to  pressure  about 
the  back  of  the  heel  on  either  side  of  the  insertion  of  the  tendon. 
In  most  cases  a  slight  swelling,  often  more  prominent  on  the  inner 
than  the  outer  side  of  the  tendon,  indicates  the  situation  of  the  bursa. 
In  the  chronic  cases  the  enlargement  of  the  bursa  is  very 
noticeable,  and,  in  addition,  the  entire  posterior  aspect  of  the  heel 
often  appears  to  be  thickened.  This  is  due  probably  to  the 
secondary  irritation  about  the  fibrous  expansion  of  the  tendon 

'  Wiener  med.  Presse,  January^S,  1893. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     731 

and  the  adjoining  periosteum.  In  many  cases  the  symptoms  are 
pronounced;  pain  is  often  felt  in  the  bottom  of  the  heel  or  it  radiates 
up  the  back  of  the  leg.  The  patient,  unable  to  use  the  power 
of  the  calf  muscle,  everts  the  foot  in  walking,  thus  subjecting 
the  arch  to  overstrain,  so  that  the  symptoms  of  the  weak  foot 
are  often  added  to  those  of  the  original  trouble.  Not  infre- 
quently, however,  the  two  afi'ections  may  be  associated  from  the 
beginning  in  one  or  the  other  foot.  The  patient  complains  much 
of  stiffness  and  weakness  at  the  ankle  and  subastragaloid  joints. 
In  acute  cases,  or  in  acute  exacerbations,  there  is  usually  burn- 
ing and  throbbing  pain  characteristic  of  inflammation,  but  in  the 
subacute  form  the  pain  is  sHght,  and  is  troublesome  only  after 
overexertion. 

Pathology .^ — The  pathological  changes  do  not  differ  from  those 
found  in  and  about  other  bursse  under  similar  conditions.  In 
the  mild  cases  the  lining  membrane  is  simply  congested,  and  the 
cavity  contains  serous  fluid.  In  the  chronic  cases  the  walls  are 
much  thickened,^  the  lining  membrane  is  fringed  and  redupli- 
cated; the  contents  are  semisolid,  and  sometimes  calcareous 
masses  are  present.  Similar  changes  are  found,  however,  in  the 
bursse  of  apparently  normal  subjects,  so  that  the  condition  of  the 
bursa  may  not  always  correspond  to  the  character  of  the  symp- 
toms. Suppuration  of  the  sac  occasionally  occurs,  and  it  may  be 
the  seat  of  tuberculous  or  syphilitic  disease.  In  cases  of  long 
standing  the  parts  adjoining  the  bursa,  the  expansion  of  the 
tendon,  and  the  periosteum  become  thickened,  so  that  the  bone 
appears  to  be  increased  in  breadth  and  may  actually  become  so. 

Treatment. — When  once  established  the  affection  is  usually 
of  a  very  chronic  nature,  as  is  explained  by  the  strain  to  which 
the  sensitive  part  is  subjected  by  the  use  of  the  foot.  It  is,  there- 
fore, important  to  apply  efficient  treatment  at  the  beginning  of 
the  affection  if  an  opportunity  is  afforded.  Efficient  treatment 
implies  absolute  rest,  and  in  all  cases  of  any  severity,  particularly 
those  of  acute  onset,  a  well-fitting  plaster  bandage  should  be 
applied  to  hold  the  foot  slightly  inverted  and  at  a  right  angle  to 
the  leg.  This  should  be  worn  until  all  symptoms  have  subsided. 
In  very  mild  cases,  following  immediately  on  a  strain  or  overuse, 
simple  rest  with  the  application  of  heat,  massage,  and  pressure 
may  be  efficient.  And  in  the  subacute  cases  the  symptoms  may 
be  relieved  by  the  application  of  a  long,  broad  band  of  adliesive 
plaster,  from  the  toes  over  the  back  of  the  heel  to  the  upper 

1  Rossler,  Deut.  Zeit.  f.  Chir.,'iBd.  Ixii-.'H.  1  and  3. 


732  ORTHOPEDIC  SURGERY 

third  of  the  calf,  the  foot  being  slightly  plantar  flexed.  This  is 
firmly  fixed  by  narrow  strips  of  plaster  about  the  metatarsus, 
the  heel,  and  the  calf.  By  this  means  pressure  is  exerted  upon 
the  bursa,  and  much  of  the  strain  is  removed  from  the  tendon. 

In  persistent  cases  a  brace  may  be  used  with  advantage  for 
the  purpose  of  preventing  strain  upon  the  tendon.  Two  lateral 
uprights  with  a  calf  band  and  padded  strap  that  crosses  the  upper 
third  of  the  leg  are  attached  to  the  shoe,  pro\dded  with  a  stop 
joint  at  the  ankle  as  used  in  the  treatment  of  paralytic  calcaneus  to 
prevent  dorsal  flexion.  (See  Talipes.)  As  the  patient  is  usually 
sensitive  to  jar,  the  heel  of  the  shoe  should  be  replaced  by  one 
of  thick  rubber.  In  connection  with  the  brace  the  stimulation 
of  the  cautery  and  the  pressure  of  the  adhesive  plaster  strapping 
seem  to  hasten  the  absorption  of  the  effusion  in  and  about  the 
bursa.  If  weakness  or  depression  of  the  arch  is  present,  as  a 
result  of  the  disability  or  combined  with  it,  a  foot-plate  should 
be  applied,  and  general  affections,  with  which  the  disability  is 
sometimes  associated,  should,  of  course,  receive  attention. 

Operative  Treatment. — In  persistent  cases,  in  which  the  symp- 
toms are  not  relieved  by  treatment,  the  enlarged  bursa  should  be 
removed  by  an  incision  on  the  inner  side  of  the  tendon,  as  the 
swelling  is  usually  most  prominent  here.  A  plaster  bandage  is 
then  applied  and  is  continued  until  the  symptoms  have  subsided. 
If  the  case  is  a  chronic  one,  it  may  be  advisable  to  divide  the 
tendo  Achillis  in  order  to  completely  remove  for  a  time  the  strain 
upon  the  sensitive  part.  A  brace  of  the  character  already  de- 
scribed may  be  used  with  advantage  for  a  time  after  the  plaster 
support  has  been  removed.  Operative  treatment  is,  of  course, 
indicated  in  acute  suppurative  inflammation,  in  tuberculous  dis- 
ease, or  if  an  exostosis  beneath  the  bursa  or  concretions  within 
the  sac  are  present,  as  shown  by  an  x-ray  negative. 

Achillobursitis  Posterior. 

Tenderness,  pain,  and  swelling  at  the  back  of  the  heel  may 
be  due  to  inflammation  of  the  small  superficial  bursa  that  lies 
between  the  .tendon  and  the  skin.  The  cause  is  usually  injury 
or  the  pressure  of  the  shoe.  The  symptoms  resemble  somewhat 
those  of  achillobursitis  anterior,  but  the  swelling  is  more  super- 
ficial, and  the  pain  is  caused  by  direct  pressure  rather  than  by 
tension  on  the  tendo  Achillis.  In  the  ordinary  case  removal  of 
the  pressure  will  at  once  relieve  the  symptoms,  but  if  the  discom- 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      733 

fort  is  considerable  a  plaster  bandage  may  be  worn  for  a  week  or 
more. 

Sensitive  points  at  the  back  of  the  heel  are  usually  caused  hy 
the  pressure  of  the  shoe.  In  rare  instances  prominent  points  or 
exostoses  of  the  os  calcis  are  present,  that  may  require  special 
protection  or  removal. 

Strain  of  the  Tendo  Achillis. 

Not  infrequently,  and  usually  as  the  result  of  strain  or  overuse 
of  the  foot,  patients  complain  of  symptoms  similar  to  those  of 
achillobursitis,  but  on  examination  one  finds  that  the  pain  and 
sensitiveness  are  referred  to  the  tendon  itself.  There  is  no  swell- 
ing at  its  insertion,  or  pain  on  lateral  pressure  on  the  os  calcis. 
The  sensitive  area  may  be  as  high  up  as  the  junction  of  the 
tendon  with  the  muscle,  and,  again,  the  midpoint  of  the  tendon 
seems  most  painful. 

The  cause  in  some  cases  may  be  a  direct  strain  of  the  tendon 
or  of  the  muscular  fibres  near  its  origin,  or  inflammation  of  its 
fibrous  covering  due  probably  to  the  same  cause.  The  treatment 
is  similar  to  that  of  the  milder  type  of  achillobursitis,  by  the 
adhesive  plaster  strapping,  by  rest,  and,  later,  by  massage. 
Recovery  is  usually  rapid. 

'  Painful  Heel — Calcaneobursitis. 

Pain  referred  to  the  bottom  of  the  heel  and  sensitiveness  to 
pressure  on  standing  are  common  symptoms  of  the  weak  or  flat- 
foot.  Pain  at  this  point  may  be  one  of  the  symptoms  of  achillo- 
bursitis also.  In  rare  instances  the  painful  point  is  clearlv 
locaHzed,  and  is  confined  to  a  small  area  in  the  neighborhood  of 
the  inner  tuberosity  of  the  os  calcis.  The  cause  of  the  symptoms 
in  such  cases  may  be  an  inflamed  bursa  lying  between  the  perios- 
teum and  the  fatty  tissue  of  the  heel.  Such  burste  may  contain 
hard  substances  or  even  a  fasciculated  neuroma.^ 

Similar  symptoms  may  be  induced  by  exostoses.  Several  of 
these  cases  have  been  reported  recently  by  Baer,'  in  wliich  tlie 
exostoses  followed  gonorrhoea,  apparently  beginning  in  the 
musculo  periosteal  attachment  of  the  flexor  brevis  digitorum. 

More  general  pain  and  sensitiveness  referred  to  the  heel  are  often 

1  Brousses  et  Bert.hier,  Tievue  de  Chir..  August,  1895. 
-  Surgery,  Gynecology,  and  Obstetrics,  July  2,  1906. 


734  ORTHOPEDIC  SURGERY 

the  result  of  direct  pressure  and  bruising  of  the  tissues  incidental 
to  overuse  of  the  feet. 

Treatment. — ^Treatment  must  be  directed  to  the  condition  of 
which  the  pain  is  a  symptom,  and,  as  has  been  stated,  it  is  most 
often  one  of  the  symptoms  of  the  weak  or  broken-down  arch. 
If  the  sensitive  point  is  localized,  and  if  the  pain  is  increased  by 
jars,  a  thick  rubber  heel  combined  with  an  inner  sole,  so  cut  out 
as  to  remove  the  direct  pressure  on  the  sensitive  point,  will  often 
reheve  the  symptoms.  In  persistent  cases,  in  which  the  sensitive 
point  is  distinctly  locaHzed,  operative  intervention  for  the  removal 
of  the  bursa  or  exostoses  is  indicated. 

Sensitiveness  due  to  direct  contusion,  or  bruising  of  the  tissues 
caused  by  overuse,  must  be  treated  by  rest  and  by  change  of 
occupation,  unless  reduction  of  the  body  weight  or  improve- 
ment in  attitudes  and  local  support  relieve  the  symptoms. 

Plantar  Neuralgia. 

Synonym. — Plantalgia. 

Pain  referred  to  the  sole  of  the  foot  and  sensitiveness  to  pressure 
on  the  plantar  fascia  are  usually  symptomatic  of  the  contracted 
foot  (cavus);  less  often  such  symptoms  accompany  the  weak  or 
broken-dowTi  arch. 

Pain,  tenderness,  and  thickening  of  the  fascia  sometimes  follow 
injury  (rupture  of  the  fascia),^  and  a  similar  condition  has  been 
described  by  Franke  as  one  of  the  sequelae  of  influenza.^  It 
may  be  present,  also,  in  the  patients  who  suffer  from  gout  or 
rheumatism. 

Treatment. — Pain  in  the  sole  of  the  foot,  symptomatic  of  the 
contracted  or  of  the  weak  foot,  may  be  relieved  by  the  treatment 
of  the  conditions  of  which  it  is  a  symptom.  In  the  rare  instances 
in  which  the  fascia  is  itself  injured  or  diseased,  local  rest,  as 
afforded  by  the  plaster  bandage,  is  indicated  until  the  acute 
symptoms  have  subsided. 

Erythromelalgia. 

Weir  MitchelP  has  described  a  series  of  cases  characterized  by 
attacks  of  heat,  redness,  pain,  and  often  swelling,  most  marked 

•  Lederhose,  Verhand.  der  Deut.  G.  f.  Chir.,  XXIII.  Kong.,  1894. 

■^  Archiv  f.  klin.  Chir..  1895,  Bd.  xlix. 

'^  American  Journal  of  the  Medical  Sciences,  1878,  vol.  Ixxvi. 


DISABILITIES  AND  DEFORMITIES  OF  TEE  FOOT     735 

about  the  soles  of  the  feet.  Of  27  cases  all  but  2  were  in  women, 
many  of  whom  were  of  a  nervous  or  neurasthenic  type.  The 
affection  appears  to  be  a  form  of  vasomotor  disturbance.  Disturb- 
ances of  the  circulation  and  burning  pain  in  the  soles  of  the  feet 
are  common  symptoms  of  the  weak  foot  and  of  alUed  affections, 
but  in  such  cases  there  is  not  the  flushing  and  swelling  character- 
istic of  erythromelalgia.  In  this  afiection  the  circulatory  disturb- 
ances are  not,  as  a  rule,  confined  to  the  feet,  but  are  seen  in  the 
legs  and  even  in  the  upper  extremities.^  It  deserves  mention  as 
a  possible  explanation  of  symptoms  in  obscure  cases.^ 

Dysbasia  Anglo  Sclerotica:^  Intermittent  Limp. 

The  title  indicates  a  sclerotic  change  in  the  bloodvessels  by 
which  the  nutrition  of  the  foot  is  impaired.  The  symptoms  are 
discomfort  in  the  feet  and  legs.  The  patient,  comfortable  when 
at  rest,  after  walking  may  begin  to  limp,  or  on  standing  to  suffer 
from  stiffness,  numbness,  and  pain.  On  examination  one  often 
notes  that  the  feet  are  cyanotic  or  of  a  dark-red  color,  and  that 
the  circulation  is  impaired.  In  more  advanced  cases  the  sclerotic 
changes  in  the  arteries  are  apparent  on  palpation  and  this  may  be 
demonstrated  in  certain  instances  by  rc-ray  pictures.  Reynaud's 
disease  represents  a  more  advanced  type  of  the  affection.  It  is 
described  because  it  is  often  mistaken  for  the  symptoms  of 
flat-foot.  In  my  own  experience  the  patients  have  been  adult 
male  Jews. 

The  treatment  aside  from  massage  and  the  Uke  is  to  adapt 
the  activity  of  the  patient  to  his  blood  supply. 

Hallux  Rigidus. 

Synonyms. — Hallux  flexus,  painful  great  toe. 

Hallux  rigidus  is  a  painful  affection  of  the  great  toe-joint, 
characterized  by  restriction  of  motion,  particularly  of  the  range 
of  dorsal  flexion.  In  advanced  cases  the  first  phalanx  may  be 
slightly  plantar  flexed,  together  with  its  metatarsal  bone;  hence 
the  name  hallux  flexus,  applied  by  Davies-Colley,  who  first  de- 
scribed the  affection. 

The  restriction  of  motion  may  be  complete,  as  implied  by  the 
term  rigidus;  the  joint  appears  unduly  prominent  or  enlarged, 

1  Kahane,  Klin,  therap.  Wochen.,  May  20,  1900. 

-  Prentiss,  Transactions  of  the  Association  of  American  Physicians,  1897,  vol.  xii.  p.  303. 

*  Erb,  Mtinch.  med.  Woch.,  1904,  No.  2. 


736 


OR  THOPEDIC  S  UR  GER  Y 


Fig.  468 


usually   slightly   congested,   and    pressure   or   forced   movement 
causes  pain. 

The  symptoms  of  which  the  patient  complains  are  a  burning 
or  throbbing  pain  in  the  joint,  increased  by  standing,  and  partic- 
ularly by  walking,  because  of  the  enforced  movement  of  the 
stiff  and  painful  articulation.  There  are  many  cases  in  which 
there  is  no  actual  deformity  of  the  joint  or  other  noticeable  change; 
the  restriction  of  motion  is  much  less,  and  the  symptoms  are  corre- 
spondingly slight. 

Etiology. — Typical  hallux  rigidus  is  most  common  in  adoles- 
cence, and  it  is  very  often  associated  with  the  weak  or  broken- 
down  foot.  In  such  cases  the  toe  is  forced 
into  the  narrow  part  of  the  shoe,  and  is  thus 
subjected  to  lateral  and  to  longitudinal  pressure, 
as  well  as  to  the  additional  strain  that  the  atti- 
tude, characteristic  of  the  weak  foot,  throws  upon 
it.  In  some  cases  the  habitual  plantar  flexion  of 
the  toe  may  be  the  result  of  an  instinctive  effort 
to  support  the  weak  arch  (hammer-toe  flat-foot — 
Nicoladoni).  In  other  instances  hallux  rigidus 
is  caused  directly  by  traumatism,  as  by  stubbing 
the  toe,  by  kicking  a  hard  object,  or  by  other 
form  of  strain  or  injury.  The  affection  appears 
to  be,  primarily,  a  form  of  periarthritis,  caused 
by  injury  or  pressure.  The  restriction  of  motion 
is  in  part  due  to  muscular  spasm,  and  in  part 
to  the  irritative  and  accommodative  changes  in 
the  ligaments  and  tendons.  In  more  advanced  cases  changes  in  the 
cartilage  and  shape  of  the  articulating  surfaces,  due  to  disuse  of 
function  and  to  pressure  and  friction,  may  be  present. 

Treatment. — If  the  rigid  and  painful  joint  is  not  associated 
with  a  weak  arch,  it  may  be  relieved  by  providing  the  patient 
with  a  proper  shoe  which  exerts  no  pressure  on  the  sensitive  part. 
Motion  of  the  joint  may  be  lessened  by  increasing  the  thickness 
of  the  sole,  or,  if  necessary,  it  may  be  entirely  restricted  by  the 
insertion  of  a  brace  of  tempered  steel  between  the  two  layers  of 
the  sole,  as  shown  in  the  diagram.  If,  as  in  some  instances,  the 
flexed  and  painful  toe  is  associated  with  rigid  flat-foot,  both 
deformities  may  be  overcorrected,  under  ana\sthesia,  and  retained 
in  proper  position  by  a  plaster  bandage,  as  a  preliminary  treatment. 
If  the  milder  type  of  painful  joint  is  associated  with  the  ordi- 
nary weak  foot,  the  treatment  of  the  latter  condition  will  usually 


The  dotted  outline 
shows  the  shape  of 
the  steel  splint  that 
may  be  inserted  in 
the  sole  of  the  shoe 
for  hallux  rigidus. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      737 

relieve  the  symptoms.  In  this  class,  particularly  among  the 
poorer  patients,  the  shoe  may  be  raised  on  the  inner  side  and 
the  sole  stiffened  by  means  of  the  wedge-shaped  sole,  as  already 
described  in  the  treatment  of  the  weak  and  flat-foot.  If  painful 
motion  is  restricted,  and  if  the  exciting  causes  of  the  disability 
are  removed,  relief  of  the  symptoms  is  usually  immediate.  In 
the  chronic  cases,  in  which  the  pathological  changes  are  more 
advanced,  excision  of  the  joint  may  be  necessar)^ 

Painful  Great  Toe-joint  in  Older  Subjects. 

A  similar  condition  of  the  joint  is  sometimes  found  in  older 
subjects.     In  many  instances  the  foot    is  well-formed,  and  the 

Fig.   469 


Hallux  rigidus  and  Hat-foot,  showing  the  i:>ersistent  flexion  of  the  toe  on  the 
metatarsal  bone. 

restriction  of  motion  in  the  joint  is  veiy  sliglit;  yet  forced  dorsal 
flexion  causes  pain,  and  long  standing  or  walking  induces  dis- 
comfort, particularly  a  dull  ache  in  the  joint  and  sharp  neuralgic 
pain  referred  to  the  terminal  phalanx.  In  some  cases  the  onset 
of  the  symptoms  may  be  ascribed  to  a  long  walk  or  "mountain 
climb,"  in  others  to  wearing  tight  shoes,  and  in  some  instances 
no  definite  cause  can  be  assigned  by  the  patient.  In  cases  of 
this  type  the  symptoms  are  often  supposed  to  be  eWdences  of 

47 


738 


ORTHOPEDIC  SUBQEBY 


gout  or  rheumatism  and  in  certain  instances  there  is  a  distinct 
hypertrophic  change  corresponding  to  Heberden's  nodes  on  the 
fingers.  Although  in  certain  instances  the  discomfort  may  be 
aggravated  by  a  constitutional  disease,  still  no  relief  can  be  obtained 
by  medication  unless  it  is  combined  with  the  local  treatment 
that  has  been  described  in  the  preceding  section.  The  relief 
afforded  by  such  treatment  alone  proves,  in  many  instances,  that 
the  affection  is  purely  local  in  its  character  (Fig.  469). 

As  has  been  mentioned,  pain  referred  to  this  joint  is  a  common 
s}Tnptom  of  the  weak  foot  and  of  the  contracted  foot  as  well.  It 
is  also  caused  by  simple  pressure  on  the  joint,  and  by  the  use  of 
improper  shoes  which  'force  the  toes  into  the  abducted  position. 

Fig.  470 


Simple  congenita)  varus,  adduction  without  inversion — a  form  of  pigeon-toe. 

In  rare  instances  pain  directly  beneath  the  great  toe  and  sensi- 
tiveness to  pressure  about  the  sesamoid  bones  seem  to  indicate  an 
inflammation  of  the  tendon  sheath  or  local  periarthritis.  If  the 
discomfort  is  persistent  the  sesamoid  bones  may  be  removed.  As 
a  rule,  such  symptoms  occur  only  in  combination  with  pain  or 
deformity  of  the  great  toe-joint.  If  the  joint  is  disorganized 
from  arthritis,  excision  may  be  advisable. 


Hallux  Varus. 

Adduction  of  the  great  toe  is  not  infrequent  in  infancy,  and  it  may 
be  associated  with  a  slight  degree  of  varus  deformity  (Fig.  470). 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     739 


Fig.  471 


The  peculiarity  attracts  the  mother's  attention  because  'of  the 
difficulty  of  drawing  on  the  socks.  In  many  instances  the  muscles 
seem  abnormally  developed,  and  the  toe  appears  to  be  somewhat 
prehensile  in  its  movements. 

Treatment.— The  abnormal  mobility  may  be  checked  by  en- 
closing the  toes  with  a  narrow  strip  of  adhesive  plaster;  in  any 
event,  the  ordinary  shoe  may  be  de- 
pended upon  to  correct  any  residual 
deformity  of  this  character.  If  the 
adducted  toe  is  combined  with  varus, 
it  represents  a  slight  degree  of  club- 
foot that  must  be  corrected  in  the 
ordinary  manner.     (See  Talipes.) 

Pigeon-toe. 

Congenital  hallux  varus  forms  one 
variety  of  what  is  known  as  pigeon-toe 
or  the  habitual  turning  in  of  the  feet 
in  walking.  The  inward  rotation  may 
be  due  also  to  bow-legs,  or  it  may  be 
an  effect  of  congenital  talipes  that 
persists  after  the  cure  of  the  defor- 
mity, or  of  the  exceptional  variety  of 
coxa  vara  in  which  the  depressed 
necks  of  the  femora  are  turned  for- 
ward. In  most  instances  pigeon-toe 
in  childhood  is  symptomatic  of  weak- 
ness either  of  the  arch  of  the  foot  or 
of  the  knees  (genu  valgum).  In  such 
cases  it  is  a  conservative  effort  of 
nature  that  serves  to  check  further 
deformity,  and  it  needs  no  treatment 
other  than  that  which  may  be  applied 
to  the  weakness  of  which  it  is  a 
symptom. 

In  the  exceptional  cases,  in  which 
the  posture  is  not  symptomatic  of 
weakness  or  the  effect  of  deformity,  the  sole  of  the  shoe  may 
be  raised  slightly  on  the  outer  border.  This  will  correct  the 
attitude  in  the  milder  type,  if  combined  with  instruction  and 
training.     In  rare  instances  the  in-toeing  seems  to  be  caused  by 


An  appliance  constructed  of  leather 
bands  and  elastic  webbing  for  the 
correction  of  in-toeing.  Name  of  the 
inventor  unknown. 


740  ORTHOPEDIC  SUBOERY 

limitation  of  the  range  of  ontward  rotation  at  the  hip-joints,  a 
restriction  that  must  be  overcome  bv  systematic  stretching  of 
the  contracted  parts.  In  these  and  in  the  more  obstinate  cases 
of  the  simple  type  apparatus  may  be  applied,  similar  to  that 
used  in  the  after-treatment  of  congenital  club-foot,  to  hold  the 
feet  in  the  proper  attitude  (Fig.  471).  It  must  be  borne  in  mind 
that  the  proper  attitude  of  the  feet  is  one  of  paralleHsm  not  of 
outward  rotation,  and  that  slight  pigeon-toe  will,  as  a  rule,  correct 
itself  as  the  child  grows  older. 

Metatarsus   Varus. 

This  is  a  deformity  in  which  the  metatarsus  is  adducted  on 
the  tarsal  bones.  It  may  be  congenital  as  an  accompaniment  of 
talipes  varus,  it  maybe  a  compensatory  effect  of  valgus  deformity 
or  knock-knee.  Varus  deformity  of  the  first  metatarsal  bone  is  a 
constant  accompaniment  of  hallux  valgus. 

Hallux  Valgus. 

Hallux  valgus  is  a  deformity  in  which  the  great  toe  is  turned 
outward  to  an  exaggerated  degree.  Outward  deviation  of  the  toe 
is  so  common,  owing  to  the  use  of  improper  shoes,  that  it  is  not 
recognized  as  a  deformity,  at  least  from  the  popular  standpoint, 
unless  the  joint  appears  to  be  much  "enlarged,"  forming  a  so-called 
bunion. 

Hallux  valgus  is  practically  a  partial  dislocation  of  the  phalanx 
upon  the  metatarsal  bone.  In  well-marked  cases  the  metatarsal 
bone  is  adducted  or  turned  inward,  so  that  an  abnormal  interval 
separates  its  head  from  its  fellows,  while  the  phalanx  is  displaced 
outward  and  articulates  only  with  the  outer  condyle.  The  angle 
thus  formed,  or,  more  properly,  the  inner  condyle  of  the  adducted 
metatarsal  bone,  makes  the  prominent  or  "outgrown"  joint  (Fig. 
481).  This  projects  sharply  beneath  the  skin,  and  is  exposed  to 
injury  and  to  the  pressure  of  the  shoe;  thus  a  bursa  develops 
beneath  the  skin,  while  a  corn  or  callus  forms  on  its  superficial 
surface.  The  projecting  bone,  covered  by  the  irritated  bursa  and 
the  thickened  skin,  makes  up  the  bunion. 

In  many  instanc-es  the  other  toes  are  displaced  outward,  in 
the  direction  corresp(jii(iing  to  that  of  the  great  toe,  or  this  may 
be  rotated  on  its  long  axis  and  lie  above  or  beneath  its  fellows. 

Pathology. — The  pathological  changes  are  such  as  usually 
follow  defoririity,  disuse  (;f  function,  and   injury.     The  cartilage 


DISABILITIES  AND  DEFORMITIES  OF* THE  FOOT     74 1 

on  the  exposed  condyle  atrophies,  the  sesamoid  bones,  together 
with  the  tendon,  are  displaced  outward,  the  tissues  on  the  outer 
side  undergo  accommodative  shortening,  while  those  on  the  inner 
side  are  correspondingly  lengthened  and  attenuated.  The  surface 
of  the  bone  beneath  the  irritated  periosteum  is  often  roughened 
and  irregular,  and  exostoses  may  form  about  the  condyle,  and 
thus  aggravate  the  effects  of  the  lateral  pressure. 

Etiology. — The  deformity  is  the  direct  effect  of  shoes  that  are 
too  narrow  and  of  improper  shape,  and  in  some  instances  too 
short  for  the  foot,  so  that  the  great  toe  is  subjected  to  lateral 
and  longitudinal  pressure.  The  deforming  efi'ect  of  the  shoe  is 
increased  if  the  arch  is  w'eak,  so  that  the  toe  is  forced  forward 
into  the  narrower  part  of  the  shoe  when  the  foot  is  in  use.  The 
deformity  may  be  increased  by  injury  or  by  the  changes  that 
follow  gout,  rheumatism,  rheumatoid  arthritis  and  the  like,  and 
in  rare  instances  the  distortion  may  be  the  direct  result  of  such 
diseases;  but  all  other  factors  are  of  slight  importance  when 
compared  to  the  deforming  influence  of  the  ordinary  shoe.  The 
deformity  begins  at  a  very  early  age;  it  advances  more  rapidly 
during  adolescence,  but  the  symptoms  do  not  often  become 
troublesome  until  later  years.  Both  toes  are  affected,  as  a  rule, 
although  the  deformity  and  its  accompanying  symptoms  are 
usually  more  marked  on  one  side. 

Symptoms. — As  has  been  stated,  the  slighter  grades  of  defor- 
mity are  not  recognized  as  such,  and  it  is  usually  because  of 
the  pain  due  to  the  irritated  com  or  bursa,  and  incidentally 
because  of  the  outgrown  joint,  that  the  patients  apply  for 
treatment. 

Treatment. — The  symptoms  in  the  ordinaiy  cases  may  be 
relieved  by  providing  a  proper  shoe,  by  which  pressure  on  the 
joint  is  completely  removed  (Figs.  447  and  478).  The  sole 
should  be  strong,  and  it  should  be  sHghtly  thicker  along  the  inner 
side,  so  that  the  sensitive  joint  may  be  inclined  away  from  the 
upper  leather.  In  cases  in  which  the  deformity  is  not  far  advanced 
the  use  of  a  suitable  shoe  that  allows  space  for  an  improved  position 
of  the  great  toe,  combined  with  methodical  manual  correction 
of  the  deformity  and  exercise  of  the  disused  muscles  while  the 
toe  is  guided  in  the  proper  directions  by  the  fingers,  Avill  relieve 
the  symptoms  promptly  and  practically  cure  the  deformity.  If 
the  longitudinal  or  the  metatarsal  arches  are  depressed  they  should 
be  properly  supported  (Figs.  443  and  465). 

Several  forms  of  correcting  braces  have  been  de\ised,  to  be 


742  OB THOPEBIG  S  UB QEB  Y 

worn  during  the  day,  a  digitated  stocking  and  special  shoe  being, 
of  course,  necessar}\ 

A  simple  de'S'ice  for  holding  the  toe  in  an  improved  position 
is  the  Holden  toe-post,  recommended  by  Walsham  and  Hughes. 
This  is  a  thin  piece  of  metal  so  fixed  in  the  front  and  inner  side 
of  the  sole  of  the  shoe  that  it  separates  the  first  and  second  toes 
from  one  another  and  holds  the  former  in  an  improved  position. 
It,  of  course,  necessitates  a  special  shoe  and  a  special  shoemaker 
to  fit  it  in  its  proper  place. 

Sampson'^  makes  the  toe-post  of  tin  and  places  it  in  a  card- 
board inner  sole,  as  illustrated  in  the  diagrams  (Figs.  472  to  475). 

The  use  of  a  splint  at  night  is  also  of  some  service.  For  this 
purpose  a  piece  of  celluloid  about  one-eighth  inch  in  thickness,  one 
inch  in  width,  and  about  six  inches  in  length  may  be  used.  This, 
having  been  moulded  to  the  proper  contour  by  placing  it  in  hot 
water,  is  secured  by  tapes  to  the  inner  side  of  the  toe  and  foot. 

It  may  be  stated  that  in  the  class  of  cases  that  can  be  success- 
fully treated  by  mechanical  correction  few  patients  will  be  found 
who  are  sufficiently  interested  in  the  cure  of  the  deformity  to 
submit  to  the  sHght  discomfort  that  the  wearing  of  even  a 
carefully  adjusted  brace  entails. 

Operative  Treatment. — In  cases  in  which  the  deformity  is  of 
long  standing,  and  in  which  the  projecting  condyle  or  the  exostoses 
make  protection  of  the  sensitive  joint  difficult,  an  operation  is 
indicated.  The  primary  object  of  the  operation  is  to  remove 
the  projecting  bone.  This  may  be  accomplished  by  a  slightly 
curved  incision  about  the  inner  aspect  of  the  condyle,  the  centre 
being  below  the  joint,  so  that  the  scar  will  not  be  subjected  to 
pressure.  The  flap  of  skin  is  raised,  the  periosteum  and  part  of 
the  capsule  are  lifted  from  the  bone,  and  the  projecting  bone  is 
removed  with  a  chisel,  so  that  the  surface  is  made  perfectly 
smooth.  Contracted  tissues  that  resist  a  corrected  position  of 
the  toe  are  stretched  or  divided,  and  the  wound  having  been 
closed  with  sutures  a  plaster  bandage  is  applied  about  the  foot 
and  toe.  This  may  be  wom  with  advantage  for  several  weeks. 
The  after-treatment  consists  in  the  use  of  a  proper  shoe  and  daily 
manual  adduction  of  the  toe,  in  order  to  retain  the  improved 
position. 

Cuneiform  osteotomy  of  the  metatarsal  bone  is  an  effective 
operation  if  the  base  of  the  wedge  includes  the  projecting  bone. 

*  Johns  Hopkins  Bulletin,  .January,  1902. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     743 

Resection  of  the  head  of  the  metatarsal  bone  is  the  most  effective 
operation  if  the  deformity  is  extreme. 

As  has  been  stated  hallux  valgus   is  often  combined  with  the 


Fio.  472 


Gf 


E 


H 


D 


3 


Making  the  pattern  for  a  toe-post.  A  heavy  piece  of  paper  folded  once  along  the  line  A  B, 
A  D  E  and  B  C  F  are  cut  away,  leaving  the  tongue  A  D  C  B.  AD  should  equal  the  depth 
of  the  shoe  at  that  point,  and  A  B  should  be  as  wide  as  the  length  of  the  slit  in  the  card- 
board inner  sole.  The  tongue  is  inserted  in  the  slit,  and  the  bases  folded  back  and  cut  away 
to  conform  to  the  front  of  the  inner  sole.  When  removed  and  straightened  out  this  forms 
the  pattern  in  Fig.  473. 

Fig.  473 


B 


D 


H 


B 


F 


Pattern  of  paper  from  which  the  tin  is  cut.  The  edges  D  Z>  and  C  C  are  to  be  turned  in.  Tin 
is  folded  along  the  dotted  lines  A  B  — D  C  and  D  C  forming'the  toe-post  in  Fig.  474. 


Shows  the  toe-post  ready  to  be  inserted  into  the  cardboard  inner  sole.  Rough  points  on 
the  upper  and  under  surfaces  of  the  base,  which  are  made  by  punching  holes  with  an  awl, 
hold  the  toe-post  to  both  the  inner  sole  of  the  shoe  and  the  cardboard  inner  sole. 

Fig.  475 


Cardboard  inner  sole  with  toe-post  and  foot  adductor  attached.     (Sampson.) 


weak  or  broken-down  arch;  in  such  cases  the  foot  must  be  suj> 
ported  by  a  properly  fitted  brace.  This  is  of  special  importance 
after  treatment  by  operation. 


744  ORTHOPEDIC  SURGERY 

Bunion. — The  discomfort  of  hallux  valgus  is  caused  in  great 
part  by  the  irritated  bursa  and  the  overlying  callus.  These  symp- 
toms may  be  relieved  by  rest  and  by  hot  applications.  After- 
ward the  callus  or  corn  may  be  removed,  and  the  sensitive  bursa 
may  be  protected  by  a  bunion  plaster.  Operative  treatment  should 
be  deferred  until  after  the  acute  symptoms  have  subsided. 

Hammer-toe. 

Hammer-toe  is  a  contraction  of  one  of  the  toes,  usually  of  the 
second,  in  which  the  first  phalanx  is  dorsiflexed,  the  second  plantar 
flexed,  while  the  third  may  be  flexed  or  extended.  The  con- 
tracted toe  is  overlapped  by  its  fellows;  its  projecting  dorsal 
surface  is  subjected  to  the  pressure  of  the  upper  leather  of  the 
shoe,  and  the  terminal  phalanx,  forced  against  the  sole  of  the 

Fig.  476 


Hammer-toe,  haUux  valgus,  and  flat-foot. 


shoe  and  compressed  by  the  adjoining  toes,  becomes  flattened 
into  a  club  or  hammer-like  form.  The  nail  is  distorted  and 
often  "ingrown;"  in  most  cases  a  corn  or  callus  forms  upon  the 
extremity  of  the  toe,  and  a  small  bursa  and  corn  over  the  pro- 
jecting knuckle  on  the  dorsal  surface.  A  third  corn  or  callus  is 
often  found  beneath  the  head  of  the  metatarsal  bone  which  has 
been  forced  downward  by  the  flexion  of  the  toe. 

Hammer-toe  is  usually  bilateral;  it  may  be  congenital  and 
even  hereditary,  but  it  is  usually  caused  by  shoes  that  are 
too  short  and  too  narrow.  The  second  toe  is  deformed  most 
often,  because  it  is  the  longest  and  because  it  suffers  most  from 
the  lateral  compression  as  well.  The  deformity  begins,  as  a  rule, 
in  early  childhood,  when,  the  growth  of  the  foot  being  rapid,  it 
is  more  likely  to  suffer  from  the  effects  of  outgrown  shoes,  and 
socks  as  well. 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     745 

Symptoms. — The  symptoms  are  practically  those  of  the  corns 
or  blisters  caused  by  the  pressure  of  the  shoe,  but  they  are  often 
sufficiently  troublesome  to  interfere  seriously  not  only  with  the 
comfort,  but  with  the  abiUty  of  the  patient. 

Treatment. — The  resistance  to  the  rectification  of  the  deformity 
is  caused  by  the  accommodative  changes  that  follow  habitual  mal- 
position. In  cases  of  long  standing  all  the  tissues  may  be  involved 
in  the  contraction,  of  which  the  most  resistant  are  the  short- 
ened capsular  and  lateral  hgaments  of  the  first  interphalangeal 
joint. 

The  congenital  hammer-toe  of  the  infant  may  be  treated  by 
manipulation.  When  the  resistance  is  overcome  the  toe  may  be 
held  in  proper  position  by  narrow  strips  of  adhesive  plaster  passed 
over  and  under  it  and  about  its  fellows.  In  older  children  a 
digitation  in  the  stocking  will  often  hold  the  toe  in  place  if  the 
deformity  is  slight  and  if  a  wide  shoe  is  worn.  In  adult  cases, 
in  addition  to  the  manipulation  and  shoe,  a  retention  apparatus, 
in  the  form  of  a  light  plantar  spHnt,  or  stiffened  inner  sole  to 
which  the  toe  can  be  attached,  should  be  worn.  If  the  deformity 
is  more  resistant  the  toe  may  be  straightened  by  force,  aided,  if 
necessary,  by  the  subcutaneous  division  of  the  contracted  ligaments; 
but  in  ordinary  cases  the  only  effective  treatment  is  resection  of 
the  joint.  Sufficient  bone  should  be  removed  to  permit  the  cor- 
rection of  the  deformity,  or,  in  case  of  its  recurrence,  to  prevent 
the  projection  of  the  joint  above  its  fellows.  A  sphnt  of  celluloid 
or  other  material  should  be  worn  for  a  time.  By  this  operation 
permanent  relief  may  be  assured,  and  it  is  to  be  preferred  to  the 
mutilation  of  amputation. 

Overlapping  Toes. 

Overlapping  toes  are  veiy  common  among  adults,  owing  to  the 
pressure  of  the  narrow  shoe;  and  not  infrequently  such  deformity 
is  seen  in  infancy  of  apparently  congenital  origin.  Deflected  or 
deformed  toes  may  be  treated  in  infancy  by  manipulation  and  by 
support  with  strips  of  adhesive  plaster  in  the  manner  described. 

In  childhood  persistent  niaiuial  correction  and  proper  shoes 
will  usually  overcome  acquired  deformity.  In  older  subjects  an 
inner  sole  somewhat  Uke  a  sandal,  to  which  the  toes  may  be 
attached  by  bands  of  tape,  may  be  employed  if  the  deformity 
is  considered  of  sufficient  importance  by  the  patient  to  demand 
treatment. 


746  ORTHOPEDIC  S  UB QEB  Y 


Exostoses  of  the  Foot. 


Simple  exostoses  of  the  foot,  as  distinct  from  those  that  are 
incidental  to  disease,  as,  for  example,  to  osteoarthritis,  are,  in 
most  instances,  induced  by  pressure  upon  a  projecting  bone 
of  a  somewhat  deformed  foot.  The  common  examples  are  the 
hypertrophy  of  the  navicular  (often  seen  in  weak  foot  of  young 
children) ,  the  projection  of  the  cuneiform  bones  on  the  dorsum  of 
the  hollow  or  contracted  foot,  the  enlargement  of  the  intemal 
condyle  of  the  first  metatarsal  bone  complicating  hallux  valgus, 
the  exostoses  on  the  posterior  aspect  of  the  os  calcis  in  achillo- 
bursitis  or  those  on  its  under  surface  that  may  be  induced  by, 
or  that  become  sensitive  to,  pressure  in  cases  of  gonorrhoeal  infec- 
tion and  the  like. 

As  a  rule,  the  treatment  of  the  deformity  of  the  foot  and  the 
removal  of  pressure  will  relieve  the  symptoms  without  othei 
treatment.  Operative  removal  is  indicated  when  such  treatment  is 
not  effective. 

Fracture  of  the  Metatarsal  Bones. 

Fracture  of  a  metatarsal  bone,  most  often  the  second  or  the 
fifth,  may  occur  without  apparent  cause  other  than  walking. 
The  pain  and  the  subsequent  sweUing  in  such  cases  may  be  inex- 
plicable until  the  diagnosis  is  made  clear  by  an  ic-ray  picture. 

Displacement  of  the  Peronei  Tendons. 

Permanent  displacement  of  these  tendons  forward  of  the  mal- 
leolus is  not  uncommon  as  a  result  of  paralytic  deformity,  par- 
ticularly talipes  calcaneus,  and  in  such  instances  it  gives  rise  to 
no  symptoms.  Displacement  of  one  or  both  of  the  tendons,  or 
rather  a  laxity  of  their  attachments  that  allows  an  occasional 
displacement  or  slipping  from  the  groove  behind  the  malleolus, 
may  result  in  serious  disability,  because  of  the  pain  that  follows 
the  displacement  and  because  of  the  weakness  and  insecurity  of 
which  the  patient  usually  complains. 

The  cause  of  the  laxity  of  the  tissues  that  allows  displacement 
in  feet  otherwise  normal  may  have  been  injury,  but  as  the  affec- 
tion is  often  bilateral,  the  predisposition  may  be  congenital. 

Treatment. — If  the  displacement  is  recent,  as  when  it  follows 
injury,  the  tendons  should  be  replaced,  and  the  foot  should  be 
fixed  in  a  plaster  bandage  until  repair  has  taken  place.     If,  as 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT      747 

in  certain  instances,  dorsal  flexion  is  limited,  the  restriction  should 
be  overcome  before  the  bandage  is  applied.  If  the  displacement 
is  habitual,  a  brace  may  be  applied  to  restrain  those  motions 
at  the  ankle  that  induce  it.  In  the  chronic  cases  an  operation 
with  the  aim  of  fixing  the  tendons  by  deepening  the  groove  in 
the  malleolus,  or  by  suturing  the  displaced  sheath  in  its  normal 
position,  may  be  indicated.  If  on  examination  the  cause  of  the 
displacement  appears  to  be  a  shortening  of  the  tendon  it  may 
be  divided  and  lengthened  in  the  ordinary  manner. 

Shoes. 

The  shoe  as  a  factor  in  the  etiology  of  deformity  and  disability 
has  been  mentioned  se\eral  times  in  the  preceding  pages,  but  it 
is  a  subject  of  such  importance  that  it  deserves  especial  consider- 
ation. 

The  object  of  the  shoe  is  to  cover  and  protect  the  foot ;  therefore, 
the  one  should  correspond  to  the  shape  of  the  other.  If  the  feet 
are  placed  side  by  side  the  outline  and  the  imprint  of  the  soles 
will  correspond  to  the  accompanying  diagram  (Fig.  477).  The 
outline  demonstrates  the  actual  size  and  shape  of  the  apposed 
feet,  emphasized  by  enclosing  them  in  straight  lines.  Thus,  each 
foot  appears  to  be  somewhat  triangular,  being  broad  at  the  front 
and  narrow  at  the  heel.  The  imprint  shows  the  area  of  bearing 
surface,  and  owing  to  the  fact  that  but  a  small  portion,  of  the  arched 
part  of  the  foot  rests  upon  the  ground  it  appears  to  be  twisted 
inward.  The  sole  of  the  shoe,  if  it  is  to  enclose  and  support  the 
bearing  surface,  must  conform  to  this  inward  turn.  It  must  be 
straight  along  the  inner  border  to  follow  the  normal  line  of  the 
great  toe,  and  a  wide  outward  sweep  will  be  necessary  in  order 
to  include  the  outline  and  thus  avoid  compression  of  tlie  outer 
border  of  the  foot  (Fig.  478). 

This  demonstration  of  the  true  form  of  the  foot  is  almost  an 
indispensable  preliminaiy  to  an  intelligent  discussion  of  the 
relative  merits  of  shoes,  and,  indeed,  it  is  somewhat  of  a  revela- 
tion to  those  who  have  thought  of  the  foot  only  as  it  has  been 
subordinated  to  the  arbitraiy  and  conventional  standard  of  the 
shoemaker.  The  shoemaker's  foot,  to  which  lasts  conform,  is  much 
narrower  than  the  actual  foot;  the  great  toe  is  not  a  powerful 
movable  member,  pix)vided  with  active  muscles,  but  is  small  and 
turns  outward,  so  that  the  forefoot  is  somewhat  pyramidal  in 
form  and  turns  upward  as  if  to  avoid  contact  with  tlie  ground. 


748 


OR  TH  OPE  Die  SURGERY 


This  imaginaiy  foot,  dra-uTi  after  the  shape  of  the  ordinary  last, 
appears  in  the  diagrams  (Figs.  479  and  480).  Upon  it  the  sole 
of  the  shoe  has  been  indicated,  to  contrast  it  with  the  shape  of 


Fig.  47 


Fig.  478 


Normal  feet. 


Proper  soles  for  normal  feet. 


that  necessary  to  include  the  outline  of  the  normal  foot.  The 
actual  foot  is  thus  compressed  laterally  by  the  shoe  until  the 
stretching  of  the  leather,  during  the  "  breaking-in"  process, 
allows  it  to  overhang  the  sole.     The  great  toe  is  forced  outward. 


Fig.  479 


Fig.  480 


Shoemaker's  feet. 


Shoemaker's  soles. 


and,  with  its  fellows,  is  compressed,  distorted,  and  lifted  off  the 
ground  by  the  rocker-shaperl  sole  (Fig.  482).  Finally,  although 
in  the  foot  there  is  a  well-marked  metatarsal  arch   (convexity 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     749 

upward),  the  sole  is  almost  invariably  fashioned  with  a  convexity 
downward.  Thus  the  foot,  according  to  the  age  at  which  the 
reshaping  process  is  begun  and  the  constancy  of  the  application, 
is  gradually  changed  in  shape  and  altered  in  function  (Fig.  481). 
This  remodelling,  however,  is  often  accompanied  by  such  dis- 
comfort that  the  individual  rebels  and  wears  a  shoe  with  a  square 

Fig.  481 


Skiagram  of  a  foot  modelled  to  fit  the  shoe,  illustrating  tlie  etiology  of  hallux  valgus. 

toe,  which,  from  the  conventional  standpoint,  is  supposed  to  show 
a  meritorious  effort  to  follow  nature.  But  the  demt)nstration  of 
the  actual  foot  makes  it  evident  that  it  is  a  properly  shaped  sole, 
which  serves  as  a  support,  not  the  part  which  projects  beyond 
the  foot,  that  is  of  importance.  If  the  shoe  with  tlie  square  toe 
is  wider,  and  straighter  on  the  inner  side  than  another  with  a 


750  OETHOPJiTHC  SUBGEMY 

pointed  toe,  it  is  in  so  far  an  improvement.  But,  as  a  matter  of 
fact,  one  of  the  worst  types  of  shoe  pro^ided  for  children,  in 
shape  ven'  like  the  old-fashioned  coffin-lid,  owes  its  popularity 
to  the  square  toe.  The  same  comment  may  be  made  on  the 
so-called  "common-sense"  shoe. 

Tlie  object  of  the  heel  is  to  make  walking  easier  by  inclining 
the  body  somewhat  forward.  The  high,  narrow  heel  is  an  inse- 
cure support,  which  induces  deformity  by  thro\sdng  more  strain 
upon  the  forefoot  and  pushing  it  forward  into  the  narrowest  part 
of  the  shoe.  The  heel  is,  of  course,  unnecessar}^  in  childhood, 
and  should  not  be  worn,  since  it  limits  the  necessity  for  and  there- 
fore the  use  of  the  normal  range  of  motion  at  the  ankle-joint. 
The  ordinary  shoe,  by  restricting  the  functional  use  of  the  foot, 
favors  awkwardness  and  improper  attitudes.  It  compresses 
the  toes,  and  is  directly  responsible  for  corns,  bunions,  ingrown 
toe-nails,  and  deformities,  and  indirectly  it  causes  or  aggravates 

Fig.  482  Fig.  483 


The  rocker  sole.  The  flat  sole. 

nearly  every  weakness  to  which  the  foot  is  liable.  This  assertion 
does  not  need  support  of  argument,  since  in  some  degree  it  has 
been  proved  by  the  personal  experience  of  every  shoe  wearer. 

The  shape  of  the  proper  shoe  corresponding  to  the  undistorted 
foot  has  already  been  demonstrated  (Fig.  478).  The  sole  should 
be  thick  enough  for  protection,  but  not  so  rigid  as  to  limit  normal 
motion;  it  should  follow  the  imprint  of  the  foot,  projecting 
somewhat  beyond  the  outline  of  the  toes;  it  should  be  flat  from 
end  to  end  and  from  side  to  side  (Fig.  483),  and  the  upper  leather 
should  be  capacious.  In  other  words,  the  front  of  the  shoe  should 
be  designed  to  pennit  and  to  encourage  normal  functional  activity, 
the  slight  adduction  of  the  great  toe,  and  the  alternate  expan- 
sion and  contraction  of  its  fellows,  as  may  be  observed  in  the 
barefoot  child.  The  heel  should  be  broad  and  low.  Most  adult 
feet  are  more  or  less  deformed,  and,  therefore,  better  suited  by  an 
improved  than  by  a  perfect  shoe.  Of  this  class,  what  is  known 
as  the  wide  Waukenphast  pattern  is  the  best.     In  selecting  shoes, 


DISABILITIES  AND  DEFORMITIES  OF  THE  FOOT     751 

the  breadth  of  sole,  the  angle  of  outward  deviation  of  the  soles 
when  the  two  are  placed  side  by  side,  and  the  capacity  of  the 
upper  leather  must  be  the  determining  points. 

The  most  effective  work  for  reform  can  be  accomplished  by 
providing  proper  shoes  for  children  and  thus  preventing  deformity. 
The  inspection  of  children's  feet  shows  that  atrophy  and  com- 
pression begin  at  a  very  early  age,  and  if  protection  could  be 
assured  during  the  period  of  rapid  growth,  serious  distortion 
might  be  prevented. 

Socks. — Although  of  far  less  importance  than  the  shoes,  the 
socks  worn  by  children  desers'e  special  mention  as  a  factor  in 
deformity,  since  they  are  often  too  short  and  too  narrow  and  are 
made  of  unyielding  material,  so  that  the  proper  action  of  the  toes 
is  restrained.  Theoretically,  the  socks,  like  the  shoes,  should  be 
rights  and  lefts;  but  if  they  are  sufficiently  large  and  of  a  texture 
to  expand  readily  to  the  shape  of  the  foot,  but  little  trouble  need 
be  anticipated  on  this  score. 


CHAPTER   XXII. 

DEFORMITIES  OF  THE  FOOT. 

Talipes. 

In  the  preceding  chapters  the  disabilities  of  the  foot,  of  which 
the  symptoms  of  pain  and  discomfort  were  of  greater  importance 
than  actual  deformity,  have  been  described.  One  now  passes  to 
the  consideration  of  the  congenital  and  acquired  disabilities,  of 
which  deformity  is  the  most  noticeable  feature. 

Fig.   484 


Paralytic   equiiiu.-.     liccuvciy   lioui    paraly.si.s,   but   deformity   persists. 

Distortions  of  the  foot  are,  practically,  fixed  positions  in  normal 
attitudes  or  what  are  exaggerations  of  normal  attitudes;  in  other 
words,  the  ordinary  deformities  can  be  voluntarily  simulated,  and 
the  centres  of  mf)tion,  at  which  the  foot  is  deformed,  are  the 
centres  of  normal    motion.     If   the   foot    has  been  fixed   in  the 


DEFORMITIES  OF  THE  FOOT  753 

abnormal  attitude  during  the  period  of  formation  and  rapid  growth, 
or  if  it  has  been  used  for  any  length  of  time  in  the  abnormal  posi- 
tion, the  deformity  becomes  exaggerated  beyond  the  possibility  of 
imitation,  and  se'-ondary  variations  in  its  shape,  size,  and  nutrition 
follow. 

The  deformities  of  the  foot  are  grouped  under  the  generic 
name  of  taUpes,  derived  from  talus  (ankle)  and  pes  (foot),  signify- 
ing, therefore,  a  form  of  deformity  in  which  the  patient  walks 
upon  his  ankles.  Talipes  was  thus  originally  synonymous  with 
the  popular  term  club-foot,  but  at  the  present  time  it  is  used 
simply  as  a  prefix  to  the  descriptive  titles  of  the  different  distor- 
tions, while  club-foot  is  usually  applied  only  to  the  most  common 
of  the  congenital  deformities,  equinovarus,  in  which  the  distorted 
foot  is  club-like  in  form. 

Varieties. — There  are  four  simple  varieties  of  the  distorted  foot 
or  talipes. 

1 .  Talipes  Equinus,  the  extended  or  plantar  flexed  foot.  In  well- 
marked  cases  the  patient  walks  upon  the  heads  of  the  metatarsal 
bones,  an  attitude  that  suggested  the  name  ecjuinus  (horse-like). 

2.  Talipes  Calcaneus,  the  dorsiflexed  foot,  in  which  the  heel  is 
prominent,  and  which  alone  bears  the  weight  in  walking;  hence, 
calcaneus  from  calcaneum,  the  heel  bone. 

In  these  forms  the  centre  of  motion  is  at  the  ankle-joint. 
Under  the  terms  equinus  and  calcaneus  are  included  not  only  the 
Cases  of  marked  deformity,  but  also  those  in  which  the  range  of 
dorsal  or  plantar  flexion  is  sufficiently  limited  to  interfere  with 
function,  even  though  the  change  in  the  contour  of  the  foot  is 
slight. 

3.  Talipes  Varus,  the  inverted  foot.  In  this  deformity  the  foot 
is  turned  in  or  adducted,  and  combined  with  the  inward  twist 
there  is  practically  always  a  corresponding  degree  of  inversion; 
that  is,  the  inner  border  of  the  sole  is  elevated  and  the  outer  border 
is  depressed,  so  tliat  the  weight  falls  to  the  outer  side  of  the  centre 
of  the  foot. 

4.  Talipes  Valgus,  the  everted  foot.  This  deformity  is  the  reverse 
of  varus.  The  foot  is  abducted  and  tlie  sole  is  everted,  so  that 
in  use  the  weight  falls  on  the  inner  border. 

In  these  forms  of  lateral  deformity  the  centres  of  motion  are  at 
the  mediotarsal  and  subastragaloid  joints. 

Compound  Deformities.— Simple  defonnitios,  in  which  the  foot 
is  persistently  extended  or  fie.xed,  or  twisted  in  or  out,  are  com- 
paratively uncommon.     More  often  they  are  combined  in  varj'ing 

48 


754 


ORTHOPEDIC  S UR GER T 


degree;  thus  the  oxerext ended  or  the  overflexed  foot  is  usually 
tw-isted  inward  or  outward,  making  four  varieties  of  compound 
deformity : 

1.  Talipes  Equinovaxus,  the  extended  and  inverted  foot. 

2.  Talipes  Equinoval^s,  the  extended  and  everted  foot. 

3.  Talipes  Calcaneovarus,  the  flexed  and  inverted  foot. 

4.  Talipes  Calcaneovalgus,  the  flexed  and  everted  foot. 

In  the  various  forms  of  talipes  the  arch  may  be  increased  or 
diminished  in   depth.     It  is,   for  example,  usually  increased  in 

Fig.   485 


Congenital  calcaneus.     In  this  form  (simple  calcaneus)  the  arch  is  obliterated. 
In  the  acquired  form  (calcaneocavus)  it  is  increased. 


calcaneus  and  equinus,  and  it  is  usually  diminished  in  valgus; 
but  this  secondary  or  subordinate  deformity  is  not  recognized 
in  the  ordinary  classification.  If  the  arch  of  the  foot  is  simply 
exaggerated,  the  condition  is  sometimes  called  pes  cavus;  if  it  is 
lessened  or  lost,  it  is  called  pes  planus.  These  slight  degrees  of 
distortion,  in  which  tlie  functional  disability  is  usually  more  im- 
portant than  the  deformity,  are  rarely  classed  as  forms  of  talipes. 
Simple  cavus,  the  hollow  or  contracted  foot,  and  pes  planus,  one 


DEFORMITIES  OF  THE  FOOT 


755 


of*  the  forms  of  the  common  weak  or  flat-foot,  have  been  described 
elsewhere.     (Chapters  XX  and  XXI.) 

Etiology — From  the  remedial  standpoint,  the  cause  of  the 
deformity  is  of  far  greater  importance  than  its  form.  Thus,  one 
divides  the  distortions  of  the  foot  into  two  groups: 

1.  The  Congenital  Form,  in  which  the  foot,  in  process  of  forma- 
tion, has  shnvly  grown  into  deformity  before  birth. 

2.  The  Acquired  Form,  in  which  the  foot,  perfect  at  birth,  has  at 
a  later  time  become  distorted. 

The  congenital  club-foot  may  be  considered  simply  as  a  twisted 
foot,  of  which  the  component  parts,  although  distorted  to  a  greater 
or  less  degree,  are  capable  of  regaining  perfect  form  and  function. 
This  is  practically  true  of  the  great  majority  of  cases,  although 

Fig.   486 


Congenital  valgus. 

there  are  instances  in  which  congenital  deformity  is  complicated 
by  defective  formation  of  the  foot  or  leg,  or  in  which  the  defor- 
mity is  caused  or  at  least  accompanied  by  paralysis;  as,  for  example, 
in  certain  forms  of  spina  bifida  or  other  congenital  defect  or  dis- 
ease of  the  nervous  apparatus. 

The  acquired  deformity  is  nearly  always  a  consequence  of 
disease  of  the  spinal  cord  (anterior  poUomyelitis).  Certain 
muscles  or  groups  of  muscles  being  paralyzed,  usually  in  early 
childhood,  the  muscular  force  of  the  foot  is  unbalanced,  and  it  is 
drawn  into  a  distorted  position  by  the  contraction  of  the  un- 
opposed muscles  and  by  the  influence  of  gravity.  This  distortion 
is  confirmed  and  increased  by  the  acconnnodative  changes  in 
structure  that  accompany  functional  use  and  grow1;h  in  the 
abnormal  attitude. 


756 


OBTHOPEDIC  SURGERY 


Far  less  often  acquired  talipes  may  be  the  result  of  paralysis  of 
cerebral  origin,  of  other  forms  of  disease  of  the  spinal  cord,  or  of 
local  paralysis  following  neuritis  or  injury  to  a  nerve  trunk.  It  may 
be  caused  by  scar  contraction,  as  after  a  severe  burn,  or  by  direct 
injur)',  or  by  disease  that  may  interfere  with  subsequent  g^o^vth 
(Fig.  289).  .Such  are,  however,  extremely  uncommon  causes. 
Thus    it  is    CM'dent    that    while  congenital   taUpes    is  a  simple 

Fig.  487 


A 


Congenital  club-hands  and  feet,  combined  with  anchylosis  of  nearly  all  the  joints. 
(Compare    with    Fig.    488.) 

distortion  capable  of  perfect  cure,  acquired  talipes  is  capable 
only  of  rectification  and  not  of  perfect  cure  unless  recoveiy  from 
the  original  disease,  of  which  it  is  a  result,  has  taken  place. 

Etiology  of  Congenital  Talipes. — As  of  other  congenital  defor- 
mities, the  cti(^logy  (jf  talipes  is  more  or  less  conjectural.  Occa- 
sionally the  influence  of  inheritance  is  apparent,  and,  again,  two 
or  more  children  with  club-foot  may  be  born  of  the  same  mother; 


DEFORMITIES  OF  THE  FOOT 


Ibl 


but,  as  a  rule,  nothing  bearing  upon  the  deformity  appears  in 
the  family  or  personal  history.  The  most  reasonable  explanation 
as  applied  to  the  majority  of  cases  is  the  mechanical.  This  is, 
in  brief,  the  theoiy  that  the  foot  has  from  some  cause  remained 
for  a  longer  or  shorter  time  in  a  constrained  or  fixed  position, 
and  has  thus  grown  into  deformity. 

It  has  been  claimed  by  Eschricht^  and  also  by  Berg^  that  about 
the  third  month  of  intrauterine    life  the  thighs  of    the  embryo 


Fig.   488 


The  etiology  of  congenital  club-luuuls,  club-foot,  and  anchylosisof  the  joints.  The  habitual 
attitude  at  birth.     Photograph  at  age  of  three  months.     (See  Fig.  487.) 

are  abducted,  flexed,  and  rotated  outward,  the  legs  are  crossed, 
and  the  feet  are  plantar  flexed  and  adducted,  so  that  the  inner 
surfaces  of  the  thighs,  the  tibial  borders  of  the  legs,  and  the  plantar 
surfaces  of  the  feet  are  held  in  close  apposition  to  the  abdomen 
and  to  the  pelvis  of  the  fa^tus.  Later  there  is  an  inward  rota- 
tion of  the  legs,  so  that  the  feet  are  turned  gradually  outward 
until  the  soles  are  brought  into   contact  with  the  uterine  wall,  the 

1  Deutsche  Klinik,   1851,  No.  44. 

*  Berg,  Archives  of  MedicLue,  New  York,  December  1,  1882. 


758  ORTHOPEDIC  SURGERY 

feet  then  being  in  the  attitude  of  abduction  and  dorsal  flexion. 
According  to  this  theory'',  there  is  a  regular  succession  of  attitudes 
durinor  intrauterine  life.  If  the  inward  rotation  of  the  lower 
extremity  is  prevented  or  if  it  is  incomplete,  the  foot,  remaining 
in  the  original  position,  becomes  deformed.  Thus  equinovarus, 
being  the  normal  attitude  of  the  early  and  middle  period  of  intra- 
uterine life,  is  not  only  the  most  common,  but  it  is  the  most 
intractable  of  the  congenital  deformities.  But  if  the  constraint 
or  pressure  is  not  exerted  until  a  later  period,  after  rotation  has 
taken  place,  when  the  foot  has  attained  or  nearly  attained  its 
normal  size  and  shape,  it  will  then  induce  the  rarer  and  compara- 
tively slight  grades  of  deformity,  such  as  calcaneus  or  valgus. 

This  theoiy,  which  seems  interesting  and  reasonable,  appears 
to  rest  on  a  very  insecure  basis.  Bessel  Hagen^  states  that  in 
embr)-os  of  30  mm.  in  length  the  foot  is  in  extreme  plantar 
flexion;  in  those  of  90  to  100  mm.  the  foot  is  at  a  right  angle  to 
the  leg;  and  from  this  size  to  that  at  full  term  the  foot  may  be 
found  in  any  position — abducted,  adducted,  or  dorsiflexed.  He 
states,  also,  that  inversion  is  not  the  usual  attitude  at  an  early 
period,  but  is  more  common  near  the  termination  of  intrauterine 
life,  and  when  it  is  present  it  is  more  often  combined  with  dorsi- 
flexion.  In  other  words,  there  is  no  time  when  the  foot  regularly 
and  normally  assumes  the  attitude  of  club-foot,  from  which  it  is 
changed  by  the  rotation  of  the  limbs.  Scudder,^  after  similar 
investigations,  arrived  at  practically  the  same  conclusions.  He 
states  that  there  is  no  necessary  relation  between  the  age,  the 
rotation  of  the  limbs,  and  the  position  of  the  feet. 

Although  the  rotation  theory  may  not  be  absolutely  accepted, 
still  it  would  appear  that  there  is,  during  the  process  of  develop- 
ment, a  normal  alternation  of  posture  of  the  limbs  and  feet.  If 
they  are  fixed  in  one  position  during  this  period  of  rapid  growth, 
distortion  must  follow;  if  the  constraint  is  slight,  and  if  its  in- 
fluence is  exerted  at  a  late  period,  the  deformity  will  be  slight; 
if  it  persists  from  an  early  period,  the  deformity  will  be  extreme 
and  resistant. 

One  of  the  causes  of  constraint,  and  thus  of  ultimate  deformity, 
appears  to  be  the  interlocking  of  the  feet.  Many  museum  speci- 
mens show  this,  and  in  some  of  the  cases  of  talipes  seen  during 
the  first  weeks  of  life  the  feet  may  be  replaced  in  the  attitude  in 
which  they  had  been  fixed  before  birth  (Fig.  310).     Intrauterine 

'  Die  Patliologie  und  Therapie  de.s  Kluinpfusses  Heidelberg,  1899. 
-  BostoQ  Medical  and  tiuigical  Journal,  October  27,  1887. 


DEFORMITIES  OF  TEE  FOOT 


759 


pressure,  although  not  usually  the  direct  cause  of  club-foot, 
undoubtedly  has  an  influence  in  aggravating  the  deformity.  The 
effect  of  pressure  is  not  infrequently  shown  in  atrophic  areas  of 
skin,  and  bursse  even  are  sometimes  found  over  prominent  bones. 

Entanglement  in  the  umbilical  cord,  the  direct  pressure  of  intra- 
uterine or  extrauterine  tumors  and  the  like  may  be  mentioned 
also  as  possible  causes. 

Evidence  of  restraint  and  of  abnormal  attitudes  of  the  limbs  is 
seen  not  infrequently  in  connection  with  club-foot;  for  example, 


Fig.  489 


Intrauterine  "aiuputatious."     The  patient  is  a  tailor. 


in  hyperextension  or  fixed  flexion  of  the  knees,  and  in  cases  of 
extreme  deformity,  the  foot  is  often  smaller  than  normal  and 
otherwise  asymmetrical.  The  distorted  foot  may  be  impei-fect 
in  structure;  toes  may  be  absent,  "spontaneous  amputation" 
(Fig.  489)  or  constricting  bands  about  the  leg  or  foot  may  be 
present.  Such  abnormalities  are  usually  ascribed  to  amniotic 
adhesions.  Talipes  may  be  combined  with  evidences  of  impaired 
or  arrested  development;  with  harelip,  extrophy  of  the  bladder, 
spina  bifida,  and  absence  of  patelhie;  or  with  other  deformities, 
such  as  club-hand  and  wr^'neck,  fixed  fle.xion  at  the  knees,  and 


760  OB  TH  OPE  Die  SUBGEBY 

the  like;  or  there  may  be  e^'idence  of  intrauterine  disease,  as 
in  anchylosis  of  joints  (Fig.  4SS)  or  so-called  foetal  rickets. 
Finally,  deformities  of  the  foot  may  accompany  or  are  caused  by 
absence  of  bones,  as  of  those  of  the  foot;  or  other  deformities  and 
malformations,  showing  e%idently  an  abnormality  in  the  original 
make-up  of  the  germ.  This  latter  group,  which  includes  the 
complications  of  club-foot  and  imperfection  of  structure,  is  com- 
paratively small,  for,  as  has  been  already  stated,  in  the  great 
majority  of  cases  congenital  club-foot  is  a  simple  deformity  capable 
of  perfect  cure. 

Statistics. — The  most  accurate  statistics  are  those  compiled 
from  the  records  of  the  Hospital  for  Ruptured  and  Crippled,* 
of  4718  individual  cases  of  talipes.  Of  these  2103  were  congenital 
and  2615  were  acquired.  The  relative  frequency  of  the  congenital 
and  acquired  forms  of  talipes  has  given  rise  to  much  discussion  in 
the  past,  and  statistics  on  this  point  are  at  considerable  variance 
'with,  one  another.  This  may  be  explained  by  the  fact  that  acquired 
talipes  is,  as  a  rule,  a  preventable  deformity.  At  the  present 
time  the  extreme  degrees  of  acquired  talipes  are  comparatively 
rare,  and  the  deformity  is  usually  of  a  much  slighter  grade  than 
the  corresponding  form  of  congenital  distortion. 

Males. 
Sex  of  congenital  talipes     ....    1355 

Percentage 64.4 

Sex  of  acquired  talipes        ....    1416 
Percentage 54.1 

Congenital  talipes  is  much  more  common  among  males  than 
among  females.  All  statistics  are  in  accord  upon  this  point. 
Acquired  talipes  is  more  equally  divided  between  the  sexes. 

Right.         Left.        Both.         Total. 
Foot  affected  in  congenital  talipes      .       .      643  552  908  2103 

Percentage 30.4  26.1  43.5 

Unilateral  1195  =  57. 5  per  cent.    Bilateral  918  =  43. 5  per  cent. 

Riqht.        Left.         Both.         Total. 
Foot  affected  in  acquired  talipes  .       .       .    1126  1102  387  2615 

Percentage 43  42.1  14.9 

Unilateral  2228  =  85. 1  per  cent.    Bilateral  387  =  14. 9  per  cent. 

In  congenital  talipes  the  deformity  is  nearly  as  often  of  both 
as  of  one  foot,  while  in  the  acquired  form  unilateral  deformity  is 
far  more  common.  In  each  variety  the  right  foot  appears  to  be 
more  often  affected  than  the  left, 

1  W.  R.  Townsend,  A  Statistical  Pajier  on  Club-foot.  Transactions  of  the  Medical 
Society  of  the  State  of  New  York,  1890.  These  statistics  of  cases  have  been  supple- 
mented for  me  by  l)rs.  Waller  and  Weingarten. 


Females. 

Total. 

748 

2103 

35.6 

1199 

2615 

45. 9~ 

DEFORMITIES  OF  THE  FOOT 


761 


The  Relative  Frequency  of  the  Different  Forms  of  Congenital 

Talipes. 

Cases.  Percentage. 

Equinovarus 1C29                 77.4 

Valgus 144                   f..8 

Varus 89                   4.2 

Calcaneovalgus 87                   4. 1 

Equinus 49                   2.3 

Calcaneus 47                 2.2 

Equinovalgus 35                  1.6 

Caicaneovarus 10 

Cavus 5 

Valgocavus 1 

Equinocavus 1 

Dififerentdeformity  in  each  foot 54 


Relative  Frequency  of  the  Different  Forms  of  Acquired  Talipes 
Together  with  the  Etiology. 


Spinal. 

Cerebral. 

Other 
forms  of 
paralysis 

Trau- 
matic. 

Total. 

Anterior 

polio- 
myelitis- 

Hemi-      Para- 
plegia,   plegia 

Per  ct. 

Equinovarus 

Equinus 

Calcaneus 

Valgus    . 

Equinovalgus 

Calcaneovalgus 

Varus 

Calcaneocavus 

Equinocavus 

Caicaneovarus 

Cavus     . 

Varocavus     . 

610 
469 
313 
205 
163 
123 
68 
13 
38 
15 
48 
2 

59 
102 
7 
6 
1 
1 
8 
0 
0 
0 
1 
1 

41 
50 
3 

10 
5 

1 
3 
1 
0 
0 
1 
1 

18 

14 

9 

0 
1 
0 

0 

56 
43 
20 
37 

7 

15    . 
10 

0 

2 

1 

4 

0 

784 
678 
352 
259 
177 
141 
90 
15 
40 
17 
54 
4 

30 
2.5.9 
13.4 
9.9 
6.7 
5.4 
3.1 
0.5 

1..0 

0.6 
0.2 

Deformity  differer 

ton 

each 

side 

2067 

186 

116              47 

195 

2611 

Anterior  poliomyelitis 

Cerebral 

Traumatic 


2067  =  79. 9  per  cent. 
302  =  11. 5       " 
195  =  7 


Comparative  Frequency  of  the  Different  Forms  of  Talipes, 
Congenital  and  Acquired, 

Congenital.  Acquired. 

Equinovarus        .       .       .       .  77. 4  per  cent.  32. 5  per  cent. 

Valgus 6.8        "  9.7        " 

Varus 4. 2       "  2. 7        " 

Calcaneovalgus  ....  4. 1       "  4. 4       " 

Equinus 2. 3       "  26.1       " 

Calcaneus 1.6       "  12.6       " 

It  will  be  noted  that  in  three-fourths  of  the  congenital  cases 
the  deformity  is  equinovarus,  and  that  equinus  and  calcaneus, 
rare  as  congenital  deformities,  comprise  38  per  cent,  of  the  acquired 
forms. 


762  ORTHOPEDIC  SURGERY 

Occasionally  the  deformity  is  different  in  each  foot,  far  more 
often  in  the  acquired  than  in  the  congenital  form  (147  of  the  former 
or  30  per  cent.,  of  the  4S4  acquired  bilateral  deformities  as  com- 
pared with  54,  or  less  than  6  per  cent.,  of  the  bilateral  congenital). 
In  7  of  IS  of  the  congenital  cases  the  deformity  was  equinovarus 
on  one  side,  calcaneus  on  the  other;  in  3,  equinovarus  and  cal- 
caneovalgus,  ■  and  in  3,  simple  varus  and  valgus.  In  congenital 
cases  the  most  common  combination  is  equinovarus  on  one  side 
and  calcaneus  on  the  other.  Next  equinovarus  and  calcaneo- 
valo'us. 

In  31,  or  4  per  cent.,  of  735  cases  of  congenital  talipes  tabu- 
lated by  Waller  the  distortion  was  combined  with  other  con- 
genital defects  or  deformities,  viz.,  in  12  cases  with  double  club- 
hands ;  in  6  cases  with  defective  development  of  the  hands,  webbed 
fingers,  and  the  like;  in  7  cases  with  spina  bifida;  in  3  cases  with 
absence  of  one  or  more  bones  of  the  leg;  in  1  case  with  torticollis 
in  1  case  with  harelip;  in  1  case  with  dislocation  of  the  knee  and 
anchylosis  of  an  elbow;  in  2  cases  with  general  rigidity  and  defor- 
mity of  the  joints. 

The  Anatomy  of  Congenital  Club-foot.  Talipes  Equinovarus. — 
Congenital  talipes  is,  in  the  great  majority  of  cases,  the  form  in 
which  the  foot  is  twisted  inward  and  downward,  so  that  in  extreme 
cases  it  resembles  the  club-like  extremity  that  has  received  the 
popular  name  of  club-foot.  The  ordinary  congenital  club-foot 
in  early  infancy  is  simply  a  foot  held  in  an  exaggerated  attitude 
of  plantar  flexion,  adduction,  and  supination.  The  dorsum  of 
the  foot  looks  forward  and  slightly  outward  and  upward,  the 
plantar  surface  is  abnormally  concave,  and  looks  backward, 
inward,  and  downward.  The  foot  often  seems  somewhat  smaller 
than  normal,  and  the  heel  appears  to  be  ill-formed.  Upon  the 
outer  dorsal  surface  the  body  of  the  displaced  astragalus  projects; 
the  external  malleolus  is  prominent,  while  the  internal  malleolus 
lies  deep  beneath  the  redundant  tissues  of  the  internal  aspect  of 
the  foot. 

In  many  instances  the  turning  inward  of  the  foot  is  so  extreme 
that  it  conceals  the  equinus  element  of  the  deformity  (Fig.  490). 
Thus  equinovai-us  is  often  classified  as  varus,  especially  by  English 
authors. 

The  internal  structure  of  the  foot  corresponds  to  the  external 
contour;  thus  the  relation  of  the  bones  to  one  another,  and  even 
the  shape  of  the  individual  bones,  are  more  or  less  altered  as  the 
deformity  is  more  or  less  of  an  exaggeration  of  the  attitudes  that 


DEFORMITIES  OF  THE  FOOT 


763 


the  normal  foot  is  capable  of  assuming.     These  changes  are  most 
marked  in  the  astragalus  and  os  calcis.     The  astragalus  is  thicker 


Fig.   490 


Typical   congenital  equinovarus   (club-foot). 
Fig.   491 


The  deformities  of  the  astragalus  in  club-foot:  A ,  astragalus  of  a  normal  infant;  1,  from 
above;  2.  from  within;  3,  from  without.  B,  the  astragalus  in  club-foot  in  the  same  posi- 
tions.    (Adams.) 

at  its  external  than  at  its  internal  border,  or  somewhat  \vedge-.shaped 
from  without  inward;  it  is  plantar  flexed,  so  that  a  large  part  of 
its  body  protrudes  from  between  the  malleoli.     Its  neck  is  often 


764  ORTHOPEDIC  SURGERY 

somewhat  longer  than  normal,  and  it  is,  as  a  rule,  depressed  and 
deflected  inward  (Fig.  491,  B).  The  os  calcis  is  also  in  an  attitude 
of  plantar  flexion ;  the  internal  tuberosity  is  draAMi  upward  to  the 
%'icinity  of  the  internal  malleolus,  its  anterior  extremity  looks  down- 
ward and  inward,  and  it  is  often  bent  inward,  corresponding 
to  the  deformity  of  the  neck  of  the  astragalus.  Its  external  sur- 
face  looks  doT\^iward  and  forward,  and  it  lies  directly  beneath 
the  astragalus  instead  of  to  its  outer  side,  as  in  the  normal  relation. 

The  na^'icular  is  drawn  inward  and  upward,  and  articulates 
with  the  inner  part  of  the  deflected  head  of  the  astragalus;  it 
lies  in  close  proximity  to  and  is  often  in  contact  with  the  internal 
malleolus;  the  cuboid  is  displaced  upward  and  inward,  and  lies 
to  the  inner  side  of  the  anterior  extremity  of  the  os  calcis.  The 
remaining  bones  are  changed  in  position,  but  not  materially  in 
shape.  In  many  instances  the  tibia  is  rotated  inward  upon  the 
femur,  and  this  inward  rotation  of  the  leg  may  persist  after  the 
deformity  of  the  foot  has  been  corrected.  Less  often  the  tibia  is 
slightly  twisted  inward  on  its  long  axis.  In. other  cases  there  is 
often  a  moderate  degree  of  knock-knee  and  laxity  of  the  liga- 
ments at  the  knee.  As  a  rule,  howeyer,  these  are  secondary  or 
compensator}'  effects  of  club-foot  that  do  not  appear  until  the 
child  begins  to  walk. 

The  ligaments  are  altered  to  correspond  to  the  changed  rela- 
tions of  the  bones.  Those  on  the  short  side  are  more  or  less 
resistant,  according  to  the  duration  of  the  deformity.  The  mus- 
cles are  normal  as  to  their  structure  and  their  origin  and  insertion, 
but  the  direction  of  the  tendons  as  they  pass  across  the  foot  is 
altered  somewhat.  Those  attached  to  the  inner  side,  the  extensor 
and  adductor  group,  are  shortened  and  are  relatiyely  stronger 
than  the  opposing  muscles  which  are  lengthened  and  atrophied 
from  disuse. 

To  sum  up:  all  the  component  parts  of  the  foot  participate  in 
the  deformity.  The  most  resistant  structures  of  the  deformed 
foot  are  the  plantar  fascia  and  the  ligaments  that  bind  the  navicular, 
the  OS  calcis,  and  the  internal  malleolus  to  one  another.  The 
muscles  that  are  most  active  in  retaining  and  increasing  the 
deformity  are  the  tibialis  anticus,  the  tibialis  posticus,  and  the 
combined  gastrocnemius  and  soleus. 

The  changes  that  have  been  outlined,  which  are  comparatively 
slight  and  which  may  be  easily  rectified  soon  after  birth,  become 
more  marked  as  the  part  develops;  and  when  the  child  begins 
to    walk   the    weight   of   the   body,   combined  with  growth  and 


DEFORMITIES  OF  THE  FOOT 


765 


functional   use  in   the   abnormal  position,  increases  and  fixes  the 
defornnity. 

In  the  adolescent  or  adult  t}^pe  of  club-foot  that  has  never 
been  treated,  the  deformity  is  so  extreme  that  the  patient  actually 
appears  to  walk  on  the  outside  of  his  ankles,  as  the  term  talipes 
implies.  The  feet  turn  directly  inward,  or  even  inward,  upward, 
and  backward,  and  the  peculiar  walk,  by  which  interference  of 
inverted  feet  is  avoided,  has 

given   another    name    (reel  ^'^-  ^^^ 

foot)  to  the  deformity. 

In  such  cases  knock-knee 
is  usually  well  marked .  This , 
although  it  may  be  present 
at  birth,  is,  as  has  been 
stated,  usually  a  secondary 
distortion  caused  in  great 
part  by  the  accommodation 
to  the  deformity;  that  is,  by 
the  diminution  of  the  base 
of  support  and  by  the  inter- 
ference of  the  feet  (Fig.  495.) 

The  legs  are  shrunken 
from  disuse.  Over  the  outer 
border  of  the  foot,  in  the 
neighborhood  of  the  calca- 
neocuboid articulation,  there 
is  a  large  callus  with  an 
underlying  bursa.  The  foot 
itself  is  atrophied  and  is 
smaller  than  the  normal. 
The  changes  in  the  bones 
are  much  more  marked ;  only 
a  small  part  of  the  articu- 
lating surface  of  the  astrag- 
alus lies  between  the  mal- 
leoli, and  this  posterior  ex- 
tremity is  flattened  out  to  the  shape  of  a  wedge.  Thus,  the  leg 
bones  appear  to  be  displaced  backward,  a  change  most  apparent 
in  the  position  of  the  external  malleolus.  The  bones  of  the  foot 
are  more  or  less  atrophied,  and  the  normal  area  of  cartilage  has, 
to  a  great  extent,  disappeared  from  the  articular  surfaces  of  the 
disused  joints. 


Talipes  equinovarus  iu  adolescence,  apparently 
of  the  acquired  form,  showing  the  displacement  of 
the  astragalus  and  its  relation  to  the  scaphoid,  also 
the  atrophy  and  distortion  of  the  bones  of  the  leg. 


766 


ORTHOPEDIC  SURGERY 


In  these  neglected  cases  the  foot  is  practically  a  simple  rigid 
support,  to  which  the  patient  has  been  so  long  accustomed  that 
he  may  walk  with  comparative  ease  and  mth  no  discomfort 
other  than  that  caused  by  the  corns  and  bunions  at  the  pres- 
sure points.  In  such  cases,  cure  in  the  sense  of  perfect  functional 
reco\ery  is,  of  course,  out  of  the  question;  but  relief  of  the  defor- 
mity— that  is,  replacement  of  the  foot  in  the  axis  of  the  leg,  at 


Fig.  493 


Fig.  494 


Talipes  equiuovarus. 
The  tendons  on  the  front  of  the  foot.         Showing  the  tendons  in  the  sole  of  the  foot  and 

the  extreme  displacement  of  the  os  calcis. 

a  right  angle  to  it  and  in  the  plantigrade  attitude — is  neariy  always 
possible. 

Symptoms. — The  symptoms  of  congenital  club-foot  have  been, 
to  all  intents,  included  in  the  description  of  the  deformity.  The 
functional  disaliility  is,  of  course,  considerable,  although  some 
patients  are  surprisingly  active  and  are  able  to  walk  long  dis- 
tances.    As  the  discomfort  from  club-foot  is  due  almost  entirely 


DEFORMITIES  OF  THE  FOOT  767 

to  the  corns  or  inflamed  bursse  over  the  bony  prominences,  its 
character  depends,  of  course,  upon  the  use  to  which  the  foot  is 
subjected. 

Treatment. — In  considering  the  treatment  of  congenital  club- 
foot it  is  customary  to  divide  it  into  several  classes  corresponding 
to  the  degree  of  resistant  deformity. 

The  first  class  would  include  the  very  slight  or  non-resistant 
cases  in  which  the  deformity  may  be  almost  entirel}'  corrected  by 
slight  manual  force. 

The  second  class  comprises  those  cases  in  which  a  certain 
amount  of  varus  and  well-marked  equinus  persist,  which  it  is 
impossible  to  overcome  by  manipulation. 

The  first  and  second  classes  include  the  forms  of  infantile 
club-foot. 

The  third  class  comprises  the  cases  of  more  extreme  deformity 
and  those  in  which  the  resistance  to  the  correction  is  great,  as  in 
many  of  the  cases  in  early  childhood  or  those  of  later  years  that 
have  been  ineflSciently  treated. 

A  fourth  class  would  include  the  untreated  cases  in  the  adoles- 
cent or  adult. 

Congenital  club-foot  (talipes  equinovarus)  treated  at  the  proper 
time — that  is  to  say,  in  early  infancy  and  in  a  proper  manner  in 
a  great  majority  of  cases  may  be  perfectly  cured  both  as  to  form 
and  function. 

The  club-foot  in  childhood,  in  which  treatment  has  been  de- 
layed or  in  which  it  has  been  ineffective,  may  be  practically  cured 
as  to  form  and  function,  but  a  certain  amount  of  atrophy  of  the 
foot  and  leg  persists  as  a  consequence  of  the  disuse  of  the  dis- 
torted part. 

Club-foot  in  the  adidt  may  be  made  straight,  but  restoration 
of  perfect  function  is,  of  course,  impossible. 

Although  congenital  club-foot  is  an  eminently  curable  defor- 
mity, yet  perfect  and  permanent  cure  requires  minute  attention 
to  details  during  the  active  stage  of  treatment,  supplemented  by 
careful  supervision  long  after  the  cure  is  supposed  to  be  com- 
plete. No  other  deformity  presents  such  a  record  of  failures 
and  incomplete  cures,  of  relapses  after  apparent  cure,  of  tedious 
and  ineffective  treatment  by  braces,  and  of  unnecessary'  and 
mutilating  operations.  Some  of  the  failures  may  be  explained  by 
the  neglect  of  the  parents  or  by  want  of  opportunity.  A  few  are 
due  to  the  unusual  obstacles  in  the  deformity  itself,  but  by  far 
the  greater  number    must    be  accounted  for  by  failure  of  the 


768  ORTHOPEDIC  SURGERY 

physician  to  apprehend  the  true  nature  of  the  deformity  or  by  his 
inexperience  in  the  practical  details  of  treatment. 

Principles  of  Treatment  of  Infantile  Club-foot. — The  infantile 
club-foot  is,  as  has  been  stated,  simply  a  twisted  foot.  It  is  true 
that  there  are  slight  changes  in  the  bones;  but  the  bones  of  an 
infant's  foot  are  represented  by  yielding  cartilage,  which  will 
rapidly  reform  under  changed  conditions.  The  shortened  liga- 
ments, which  are  accommodated  to  the  deformity,  may  be  easily 
stretched,  together  with  the  more  resistant  muscles  and  their 
tendinous  insertions,  and  when  the  proper  relation  of  the  bones 
to  one  another  has  been  restored  the  joints  will  undergo  an 
acco mmod at i ve  transf o rmation . 

The  treatment  of  club-foot  may  be  divided  into  three  stages: 

1.  The  rectification  of  the  external  deformity. 

2.  The  support  of  the  foot  in  proper  position  during  the  process 
of  transformation  of  its  internal  structure  and  until  the  normal 
muscular  power,  unbalanced  by  the  deformity,  has  been  regained. 

3.  The  period  of  supervision.  This  would  include  the  treat- 
ment of  possible  complicating  deformities  at  the  knee,  the  laxity 
of  Hgaments  and  the  like,  as  well  as  the  oversight  of  the  func- 
tional use  of  the  foot  and  the  limb  during  the  early  years  of 
life. 

On  examining  the  infantile  club-foot  one  will  notice  a  certain 
measure  of  the  muscular  activity  that  characterizes  the  normal  foot. 
The  normal  infant  moves  the  foot  in  various  directions,  in  a  more 
or  less  regular  alternation  of  postures,  but  the  motion  of  the  club- 
foot is  in  one  direction  only,  that  toward  which  the  foot  is  turned. 
The  muscles  on  the  back  and  inner  side  of  the  leg,  which  are  alone 
active,  become  relatively  irritable  and  hypertrophied  as  compared 
with  those  on  the  front  and  outer  side  that  are  disused.  Thus 
movement  of  the  deformed  foot  is  in  reality  harmful,  be- 
cause it  increases  deformity  and  still  further  disturbs  the  mus- 
cular balance.  For  this  reason  the  temporary  restraint  of  motion, 
necassary  during  the  rectification  of  the  deformity,  may  be  con- 
sidered rather  of  advantage  than  otherwise.  When  movement 
is  again  allowed  and  encouraged  it  must  be  in  the  directions 
opposed  to  the  attitudes  of  deformity,  with  the  aim  of  so  strength- 
ening the  weakened  group  of  muscles  at  the  expense  of  the  stronger 
that  the  balance  of  ninsciilur  power  may  l)e  regained. 

The  First  Stage  of  Treatment.  Rectification  of  Deformity. — It 
should  be  stated  at  once  that  "rectification  of  deformity"  does 
not  mean  apparent  symmetry,  a  misapprehension  to  wliich  the 


DEFORMITIES  OF  THE  FOOT  769 

majority  of  failures  in  treatment  may  be  ascribed.  It  means  that 
when  deformity  is  really  rectified  all  contracted  and  resistant 
parts  must  have  been  so  elongated  that  every  passive  motion  and 
attitude  possible  for  the  normal  foot  is  equally  possible  and  as 
easily  attained  in  that  which  was  deformed.  This  is  functional 
rectification  as  contrasted  with  the  simple  correction  of  deformity. 

The  most  important  part  of  the  club-foot  deformity  is  varus. 
The  foot  that  is  rolled  over  and  twisted  inward  to  the  attitude 
of  extreme  inversion  (Fig.  490)  must  be  untwisted  and  forced 
into  an  attitude  of  extreme  abduction  or  valgus,  the  so-called 
overcorrection  (Fig.  486).  Until  this  is  accompUshed  no  atten- 
tion whatever  need  be  paid  to  the  residual  equinus.  There  are 
two  reasons  for  dividing  the  procedure  into  two  parts:  First,  that 
the  attention  of  the  surgeon  may  be  concentrated  on  one  and  the 
most  important  part  of  the  deformity;  second,  because  by  this 
preliminary  untwisting  the  os  calcis  is  brought  into  the  upright 
position,  into  its  proper  relation  to  the  astragalus,  to  the  bones 
of  the  leg,  and  to  the  tendo  Achillis,  so  that  the  true  degree  of 
equinus  may  be  appreciated. 

Preliminaxy  Manipulation. — As  a  rule,  the  second  or  third  week 
of  life  is  as  early  as  mechanical  treatment  can  be  undertaken. 
Until  then  preliminaiy  manipulation  by  the  nurse,  more  particu- 
larly manual  straightening  of  the  deformity  by  gently  drawing  the 
foot  toward  abduction  and  retaining  it  in  the  improved  position 
for  a  few  minutes,  as  often  as  is  possible,  may  be  of  service  in  over- 
coming its  resistance.  As  a  treatment  by  itself,  however,  simple 
manual  correction  is  tedious  and  ineffective,  although  partial 
cures  have  been  attained  by  perseverance  in  this  means  alone. 

Mechanical  Treatment. — This  is  the  treatment  of  choice  and 
routine  for  infantile  club-foot,  and  two  methods  may  be  described: 

1.  By  the  plaster  bandage. 

2.  By  some  form  of  simple  splint. 

The  principle  of  the  two  is  essentially  the  same.  The  foot  is 
drawn  toward  an  improved  position  and  retained  there  by  the 
plaster  bandage,  or  it  may  be  fixed  to  some  form  of  metal  splint 
or  brace  whose  shape  is  gradually  changed  from  week  to  week, 
as  the  resistance  lessens. 

Gradual  Rectification  of  Deformity  by  Means  of  the  Plaster 
Bandage.— In  this  treatment  care  should  be  taken  to  avoitl  undue 
pressure,  irritation  of  the  skin,  or  insecurity  of  the  bandage.  One 
should  place  slireds  of  cotton  between  the  toes;  and  the  outer 
aspect  of  the  ankle,  where  the  skin  is  thrown  into  folds  when 

49 


770 


ORTHOPEDIC  SURGERY 


the  foot  is  straightened,  should  be  smeared  wdth  vaseline.  A 
narrow  strip  of  adhesive  plaster,  long  enough  to  reach  from  the 
knee  to  a  point  an  inch  or  more  below  the  heel,  is  applied  to  the 
outer  side  of  the  leo-.  A  thin  laver  of  cotton  is  wound  about 
the  leg,  just  below  the  knee,  in  order  to  protect  the  skin  from  the 
hard  margin  of  the  plaster  bandage,  and  a  similar  strip  is  carried 
about  the  toes.  The  foot  is  then  drawn  gently  toward  the  ab- 
ducted position  as  far  as  may  be  without  causing  discomfort. 
"\^^lile  it  is  held  in  this  attitude  a  narrow  bandage,  preferably 
flannel  or  cotton  flannel,  is  smoothly  applied  to  the  leg  and  foot, 

Fig.  495 


Neglected  club-foot,  showing  the  secondary  knock-knee. 


the  band  of  adhesive  plaster  being  drawn  out  between  the  folds 
about  the  ankle.  A  very  light  plaster  bandage  is  then  applied 
from  the  extremities  of  the  toes  to  the  upper  part  of  the  leg, 
and  into  this  bandage  the  projecting  strip  of  adhesive  plaster  is 
incorporated,  so  that  no  displacement  of  the  dressing  is  possible. 
The  turns  of  both  tlie  plaster  and  the  flannel  bandage  should  be 
made  from  within,  downward  and  outward,  so  that  the  tension  aids 
in  retaining  the  foot.  When  the  plaster  bandage,  which  during  the 
hardening  process  has  been  constantly  rubbed  and  manipulated  so 


DEFORMITIES  OF  THE  FOOT  7 71 

that  it  may  fit  the  part  perfectly,  and  which  need  not  be  thicker 
than  blotting  paper,  has  become  firm,  a  long  stocking  is  drawn 
over  it  and  is  attached  to  the  body  clothing.  At  the  end  of  a 
week  the  bandage  is  removed.  The  leg  and  foot  are  gently  bathed 
with  alcohol,  thoroughly  dried,  powdered,  and  protected  as  before, 
and  the  bandage  is  again  applied.  At  this  second  dressing  the 
irritable  adducting  muscles,  after  the  interval  of  complete  rest, 
will  be  much  less  active  and  the  contracted  tissues  will  be  less  re- 
sistant, so  that  the  foot  may  be  easily  turned  somewhat  outward 
or  beyond  the  line  of  the  leg. 

After  four  or  five  applications  of  the  bandage,  at  weekly  inter- 
vals, the  foot,  in  ordinary  cases,  can  be  held  without  resistance 
in  the  attitude  of  extreme  equinovalgus.  The  sole,  which  at 
first  looked  backward,  inward,  and  upward,  will  be  turned  in  the 
opposite  direction,  forward,  outward,  and  downward,  and  the 
inner  border  of  the  foot,  which  was  concave,  is  now  convex  (Fig. 
486).  When  the  varus  has  thus  been  overcorrected,  treatment 
is  directed  to  the  secondary  equinus.  At  first  -one  carries  the 
foot  upward  (toward  dorsal  flexion),  while  it  is  still  retained  in 
the  abducted  position,  but  after  one  or  two  treatments,  when  the 
right-angled  attitude  has  been  attained,  it  is  brought  nearer  to 
the  axis  of  the  leg.  The  everted  position,  or  the  attitude  opposed 
to  varus,  is  retained,  however,  until  correction  is  completed.  In 
correcting  the  equinus  a  certain  amount  of  force  may  be  required, 
sufficient  to  cause  some  discomfort  during  the  application  of 
the  plaster,  but  not  sufficient  to  occasion  sufi^ering  afterward.  The 
force  is  applied  to  the  entire  foot,  so  that  the  posterior  extremity 
of  the  OS  calcis  may  be  drawn  do-^iiward  by  actual  lengthening 
of  the  tendo  Achillis,  and  not,  as  is  often  the  case,  by  an  over- 
correction of  the  forefoot,  while  the  heel  remains  in  its  original 
position  of  plantar  flexion.  By  the  proper  application  of  force 
the  equinus  is  gradually  overcome;  the  sharp  indentation  or  fold 
at  the  insertion  of  the  tendo  Achillis  is  lessened,  and  the  heel 
becomes  more  prominent. 

The  reduction  of  the  equinus  may  be  somewhat  more  difficult 
than  that  of  the  varus,  but  it  should  be  entirely  corrected  in  three 
or  four  months  from  the  time  of  beo-innino-  the  treatment.  As 
has  been  stated,  correction  of  the  deformity  implies  overcorrection 
(Fig.  485);  and  it  is  well,  when  this  has  been  attained,  to  hold 
the  foot  for  several  weeks,  by  means  of  the  phister  bandage,  in 
an  attitude  of  extreme  eversion  and  dorsal  flexion  (calcaneovalgus) 
in  order  to  impress,  as  it  were,  the  new  position  upon  its  struc- 


772 


ORTHOPEDIC  SURGERY 


ture.  This  concludes  the  first  stage  of  the  treatment,  the  simple 
rectification  of  deformity. 

Correction  by  the  plaster  bandage  has  the  great  advantage 
of  placing  the  treatment  entirely  under  the  control  of  the  sur- 
geon. When  properly  applied,  the  support  fits  perfectly:  it  is 
liofht  and  clean,  and  it  holds  the  foot  in  the  desired  attitude  with- 
out  undue  pressure. 

The  disadvantages  of  the  treatment  are  due  almost  entirely  to 
its  improper  application.     For  instance,  the  bandage  may  be  too 

Fig.   496 


The  first  application  of  the  plaster  bandage,  showing  the  improved  position. 
(Compare  with  Fig.  490.) 

heavy,  or  the  padding  may  be  so  thick  that  it  does  not  retain  its 
position,  pjxcoriations  are  usually  due  to  carelessness  in  the 
application  of  the  bandage,  or  because  it  is  not  removed  in  proper 
sea.son.  The  fear  of  compression,  of  atrophy  of  muscles,  of 
stunting  the  growth  of  the  limb,  is  groundless.  At  the  end  of  the 
treatment,  the  corrected  foot  is,  as  a  rule,  larger  than  one  that 
has  remained  untreated.  'I'he  stnnted  foot  is  the  resnlt  of  non- 
treatment,  or  of  inefrcctive  treatment  by  braces  or  otherwise;  not  of 
the  enforced  rest  necessitated  by  the  proper  reduction  of  deformity. 


DEFOBMTTIES  OF  THE  FOOT 


773 


The  Rectification  of  Deformity  by  Splints  and  Braces. — Of 
mechanical  supports  there  are  many  varieties.  Complicated 
appliances  should  be  avoided  because  they  are  unnecessary  and 
because  they  serve  to  distract  attention  from  the  prime  object  of 
treatment,  the  rapid  and  systematic  correction  of  deformity.  Of 
the  simpler  braces  that  used  by  Judson  is  one  of  the  best  and 
will  serve  as  a  type  to  illustrate  this  form  of  treatment.  The 
method  of  application  may  be  descril^ed  in  Judson's  own  words: 
"The  apparatus  which  I  have  conveniently  used  to  effect  this 
reduction  before  the  child  learns  to  stand  is  a  simple  retentive 
brace  which  acts  as  a  lever,  making  pressure  on  the  outer  side 


Fig.  497 


B< 


Fro.  498 


Fig.      499 


Fig.  500 


— > 
C 


^- 


Fig.  501 


Fig.  502 


Fig. 503 


Fig.  504 


The  Judson  club-foot  splint  and  its  application. 

of  the  foot  and  ankle  at  A,  in  Figs.  497  to  500,  inclusive,  and 
counterpressure  at  two  points,  one  on  the  inner  side  of  the  leg 
at  B,  and  the  other  at  the  inner  border  of  the  foot  at  C.  It  is 
advisable  to  keep  in  mind  that  this  simple  instrument  is  a  lever, 
because  if  we  know  that  we  are  using  a  lever  with  its  three  well- 
defined  points  of  pressure  we  can  make  the  apparatus  more 
efficient  than  if  we  view  it,  in  a  more  general  way,  as  an  apparatus 
for  giving  a  better  shape  to  the  foot. 

"I  use  a  little  brace  made  of  sheet  brass,  doing  the  work  with 
a  few  simple  tools.  An  advantage  of  doing  the  work  one's  self 
is  that  there  is  no  room  for  doubt  as  to  where  the  blame  lies  if 


774  ORTHOPEDIC  SVBGERY 

the  apparatus  does  not  work  well.  Two  cuiTed  disks,  B  and  C, 
Figs,  499  and  500,  are  riveted  to  a  shank,  D,  and  thus  is  formed 
that  part  of  the  brace  which  applies  the  two  points  of  counter- 
pressure;  while,  on  the  other  hand,  the  point  of  pressure  is  brought 
into  action  by  a  third  disk  or  sliield,  A,  which  is  drawn  tightly 
against  the  outer  side  of  the  foot  and  ankle,  and  held  in  place 
by  a  strip  of  adhesive  plaster,  E,  which  includes  the  leg  and  the 
piece  which  connects  the  two  disks,  B  and  C.  The  disks  are 
lined  with  two  or  three  thicknesses  of  blanket,  easily  renewed, 
when  necessary',  ^ith  a  needle  and  thread.  These  braces  are  so 
cheap  and  easily  knocked  together  that  it  is  notliing  to  apply 
new  and  larger  ones,  using  heavier  material  for  the  shank  as  the 
child  grows.  In  general,  thi'ee  sizes  will  be  enough,  the  shanks 
being  12  gauge,  |  in.  wide;  14  gauge,  ^  in.  wide;  and  16  gauge,  f  in. 
wide.  The  disks  are  conveniently  made  from  22  gauge,  1^^  in. 
wide.  The  rivets  are  copper  belt-rivets.  No.  13.  A  lip  turned 
on  the  edges  of  the  disks,  with  the  flat  pliers,  gives  stiffness  to 
the  thin  brass  and  protects  the  skin  from  the  rough  edge.  If 
more  easily  obtained,  tin  disks,  light  bars  of  iron  or  steel,  and 
ordinary  iron  rivets  would  doubtless  answer. 

"The  brace  is  applied  with  three  strips  of  adhesive  plaster. 
The  upper  and  lower  pieces,  E  and  G,  Fig.  500,  are  simply  to 
keep  the  apparatus  in  place,  which  they  do  effectively  if  ordinary 
gum  plaster  is  used;  while  by  drawing  the  middle  strip  E,  tightly 
over  the  shield,  and  straightening  the  brace  from  time  to  time, 
the  deformity  is  gradually  and  gently  reduced.  At  each  reappli- 
cation  the  brace  is  made  a  little  straighter  than  the  foot  at  that 
stage.  This  may  readily  be  done  by  the  hands,  and  then  the 
adhesive  strip  is  to  be  tightened  over  the  shield  until  the  shape  of 
the  foot  agrees  with  that  of  the  brace.  After  a  few  days  the  brace 
is  to  be  made  still  straighter  and  again  reapplied,  and  made  tight 
until  another  point  of  improvement  is  gained.  The  brace  is  applied 
very  crooked  at  the  beginning  of  treatment,  as  in  Figs.  499  and 
500,  and  is  straightened  from  time  to  time,  and  a  longer  brace 
applied  as  the  deformity  is  reduced  and  the  patient  grows.  It 
should  be  removed  every  week  or  two  weeks,  and  an  interval 
of  a  few  days  allowed  for  freedom  from  the  brace,  when  the 
mother  is  advised  to  manipulate  the  foot  constantly,  using  as 
much  force  as  she  will  in  the  direction  of  symmetiy.  Manipu- 
lating the  foot  during  these  intervals  is  of  great  importance,  as 
cases  have  occurred  in  which  varus  and  equinus  have  been  entirely 
overcome  by  the  mf>ther's  hand  alone. 


DEFORMITIES  OF  THE  FOOT  775 

"By  this  simple  and  prosy  treatment,  carried  out  systematically 
and  without  haste,  or  violence  or  pain,  the  foot,  unless  it  is  a 
frightful  exception,  may  with  certainty  be  changed  from  varus  to 
valgus.  At  the  same  time  the  tendo  Achillis  is  lengthened  until 
the  position  of  the  foot  is  near  the  normal,  or  at  right  angles 
with  the  leg,  as  the  result  of  manipulation  and  giving  the  brace 
from  time  to  time  a  partly  anteroposterior  action.  Figs.  499  and 
500  show  approximately  the  shape  of  the  brace  at  the  beginning 
of  treatment;  Figs.  501  and  502  when  the  varus  is  reduced,  and 
Figs.  503  and  504  when  valgus  has  taken  the  place  of  varus. 
The  foot,  in  this  latter  stage,  may  not  hold  itself  valgus  when 
left  to  itself,  but  with  almost  no  force  and  with  one  finger  it  ma;y 
be  pushed  into  valgus." 

When  the  varus  deformity  is  reduced  the  equinus  is  gradually 
corrected  by  carrying  the  splint  behind  the  internal  malleolus; 
and,  finally,  if  necessary,  direct  upward  pressure  may  be  applied 
by  lengthening  the  brace  and  applying  it  to  the  posterior  aspect  of 
the  foot  and  leg.  It  may  be  noted  that  manipulation  and  stretching 
the  contracted  parts  when  the  brace  is  removed  is  of  much  im- 
portance in  the  correction  of  deformity  by  this  or  other  means. 
Splints  of  wood,  tin,  felt,  and  the  like  may  be  employed,  but  they 
present  no  particular  advantage  over  that  which  has  been 
described . 

Tenotomy. — ^The  equinus  has  been  spoken  of  as  the  secondary' 
deformity,  but  its  complete  correction  is  often  more  difficult  tlian 
that  of  varus.  In  many  instances,  especially  in  the  treatment  of 
older  children,  time  will  be  gained,  after  the  foot  has  been  forced 
into  the  position  of  equinovalgus,  by  the  di^'ision  of  the  tendo 
Achillis,  which  is  the  most  resistant  of  the  shortened  tissues. 
After  division  of  the  tendon  it  may  be  necessary  to  use  consider- 
able force  to  stretch  the  other  contracted  parts,  and  to  force  the 
foot  up  to  the  limit  of  normal  dorsal  flexion,  which  is  the  object 
of  the  operation.  Occasionally  the  obstacle  seems  to  be  in  the 
posterior  ligament  of  the  ankle,  and  it  is  sometimes  of  service  to 
reinsert  the  knife  and  to  divide  this  structure,  in  part  at  least, 
so  that  it  will  give  way  under  manipulation.  When  the  foot 
has  been  forced  into  the  position  of  overcorrection  it  is  fixed  in 
a  plaster  bandage,  which  is  allowed  to  remain  for  several  weeks, 
until  the  interv^al  between  the  separated  ends  of  the  tendon  is 
filled  in  with  the  new  tissue. 

In  some  instances  the  leg  is  rotated  inward  upon  the  thigh, 
and  the  habitual  attitude  is  accompanied  by  accommodative 
changes  in  the  ligaments  of  the  knee-joint.     During  the  treat- 


776  ORTHOPEDIC  SURGERY 

ment  of  the  club-foot  tliis  secondary  distortion  may  be,  in  part 
at  least,  corrected  by  forcible  manual  rotation  of  the  leg  outward 
on  the  thigh  several  times  daily.  If  the  leg  is  slightly  bowed  it 
may  be  corrected  by  manipulation.     (See  bow-leg.) 

Recapitulation. — The  routine  treatment  of  infantile  club-foot  is, 
then:  manipulation  of  the  foot  by  the  nurse  from  birth  until 
systematic  rectification  can  be  begun;  mechanical  correction, 
first  of  the  varus  and  then  of  the  equinus  deformity,  terminating 
with  a  period  of  retention  in  the  overcorrected  position  (calcaneo- 
valgus).  Division  of  tendons,  other  than  the  tendo  Achillis,  is 
not  often  necessary.  The  time  required  for  the  overcorrection  of 
deformity  should  not,  under  favorable  conditions,  exceed  three 
months. 

The  rapid  correction  of  deformity  in  the  manner  described, 
begun  as  early  as  possible  and  accomplished  as  quickly  as  pos- 
sible, cannot  be  too  strongly  urged.  In  the  first  months  of  life 
the  tissues  are  not  resistant,  the  bones  are  practically  entirely 
cartilaginous,  and  when  the  foot  in  its  external  appearance  is 
rectified  the  rapid  growth  in  the  first  months  of  life  will  change 
the  internal  stmcture  to  conform  to  the  normal  conditions.  The 
fear  of  atrophy,  compression,  or  other  harm  from  the  temporary- 
fixation  necessary  during  rectification  is  groundless,  and,  in  fact, 
exercise,  so-called,  except  in  the  directions  opposed  to  deformity, 
is  harmful  rather  than  beneficial. 

Correction  of  deformity  may  be  accomplished  by  holding  the 
foot  in  an  improved  position  by  strips  of  adhesive  plaster,  or  by 
the  elastic  traction  of  rubber  bands  attached  to  the  leg  and  foot. 
As  compared  with  the  ease,  rapidity,  and  certainty  of  correction 
by  means  of  the  plaster  bandage  such  methods  are  uncertain  and 
inefi'ective,  and  they  need  not  be  described  in  detail. 

The  Second  Stage  of  Treatment.  Support  and  Restoration  of 
Function. — When  the  deformed  foot  has  been  corrected,  in  the 
sense  that  all  normal  motions  can  be  carried  out  by  passive  force, 
the  first  and  most  difficult  part  of  the  treatment  will  have  been 
completed,  and,  in  some  instances,  the  deformity  is  actually  cured, 
as  in  the  slighter  types  of  cases  treated  in  early  infancy.  Such  a 
result  is  unusual,  however,  for  although  the  foot  may  be  normal 
in  appearance,  its  muscular  balance  has  not  been  restored.  This 
is  shown  by  the  fact  that  when  support  is  removed  the  foot  usually 
hangs  downward  and  inward,  and  there  is  little  apparent  power 


DEFORMITIES  OF  THE  FOOT  'J  11 

in  the  dorsiflexors  and  abductors  to  draw  it  upward  and  outward. 
If  at  this  stage  treatment  were  abandoned,  the  deformity  would 
almost  invariably  recur,  at  least  in  part.  For  this  reason  the  foot 
must  be  supported  in  proper  position  until  the  slack  of  the  length- 
ened tissues  has  been  taken  up  by  development  in  the  normal 
attitude,  a  development  tliat  may  be  aided  by  massage  and  other 
forms  of  stimulation  of  the  muscles.  Practically,  support  is  always 
necessaiy  until  the  child  has  begun  to  walk. 

The  Retention  Brace. — ^The  form  of  retention  brace  will 
vaiy  somewhat  according  to  the  indications  of  the  individual  case. 
The  object  is  to  hold  the  foot  in  what  is  called  the  overcorrected 
attitude — that  is,  dorsiflexion  and  eversion.  This  may  be  accom- 
plished by  splints  of  pasteboard,  leather,  tin,  and  the  like;  but 
a  light  metal  brace  provided  with  a  sole  plate  and  upright,  as 
shown  in  Figs.  478  and  484,  is  preferable.  The  best  support  is  the 
Taylor  brace,  the  invention  of  Dr.  C.  F.  Taylor,  of  New  York 
(Fig.  505).  Tliis  consists  essentially  of  a  light  upright  that  extends 
along  the  inner  side  of  the  leg  to  the  knee,  and  a  thin  steel  foot 
plate  of  the  exact  size  of  the  sole,  with  an  upright  flange  on  the 
inner  side,  rising  to  a  point  just  above  the  dorsal  surface  of  the 
foot,  against  which  the  foot  is  pressed  closely,  so  that  recurrence 
of  the  varus  deformity  is  prevented.  The  joint  at  the  ankle  is 
provided  with  a  catch  that  prevents  plantar  flexion,  but  allows 
dorsiflexion.  By  bending  the  upright  and  the  sole  plate  the  foot 
may  be  held  in  sHght  eversion.  The  apparatus  is  applied  with 
straps,  as  illustrated,  and,  if  necessary,  its  position  is  further 
fixed  by  a  band  of  adhesive  plaster,  applied  on  the  inner  side 
of  the  leg  to  hold  the  heel  firmly  against  the  foot-plate.  The 
foot  is  thus  held  constantly  at  a  right  angle  to  the  leg,  or,  better, 
in  the  early  stage  of  treatment,  in  an  attitude  of  dorsiflexion  and 
valgus.  Occasionally,  after  complete  rectification  of  the  deformity, 
the  foot  still  turns  in.  In  most  instances  this  is  due  to  an  inwartl 
rotation  of  the  tibia  on  the  femur  at  the  knee-joint,  but  in 
some  cases  it  is  caused  by  a  spiral  twist  of  the  tibia  itself.  In 
order  to  correct  this  secondaiy  deformity  an  extension  of  the 
upright  of  the  brace  is  carried  beneath  the  leg,  provided  with  a 
joint  at  the  knee,  and  is  extended  up  the  outer  side  of  the  thigh. 
At  the  hip  it  is  attached  by  a  free  joint  to  a  padded  pelvic  band 
of  light  steel  (Fig.  510).  The  band  holds  the  upright  in  the 
proper  relation  to  the  thigh;  thus,  by  twisting  the  part  below  the 
knee  the  foot  can  be  rotated  outward  to  the  desired  degree.     In 


778 


OR THOPEDIC  S UR GER Y 


less  marked  cases  the  retention  bands  used  for  pigeon-toe  may 
be  employed  (Fig.  471). 


Fig.   505 


The  Taylor  club-foot  brace. 


Fig.  506 


Fig.  607 


'JayJor  club-f<,ot  braco.  Hhowin^  tlie  method  of  application  and  attaclmierit. 


DEFORMITIES  OF  THE  FOOT 


779 


Methodical  Manual  Correction. — Several  times  during 
the  day  the  brace  should  be  removed  in  order  that  the  foot  may 
be  thoroughly  massaged  and  forcibly  turned,  first  toward  valgus 
— ^that  is,  outward  at  the  mediotarsal  joint — so  that  the  inner 
border  is  made  convex,  and  then  to  the  extreme  limit  of  dorsi- 
fliexion  and  abduction.  If  the  leg  is  rotated  inward  it  is  forcibly 
rotated  outward  on  the  femur.  Even  if  the  tibia  is  actually 
twisted  on  its  long  axis,  the  influence  of  the  brace  and  forcible 
manipulation  will  usually  correct  the  deformity.  Active  contrac- 
tion of  the  weak  muscles  may  be  induced  by  tickling  the  sole  of 


Fig.  509 


The  Taylor  club-foot  brace,  showing  the  adhesive  plaster,  by  means  of  which  the  heel  is 
held  down,  and  the  method  of  attachment.  This  brace  may  be  used  to  correct  deformity  as 
well  as  to  retain  the  foot  in  proper  position,  as  is  illustrated  by  these  figures.  As  a  retention 
apparatus  the  foot-plate  should  be  held  at  a  right  angle  to  the  upright  by  the  stop-joint 
shown  in  Fig.  505. 

the  foot  or  by  the  use  of  electricity,  and,  finally,  the  entire  limb 
should  be  thoroughly  massaged  before  the  brace  is  reapplied. 

When  the  deformity  shows  no  tendency  to  recur  the  brace  may 
be  removed  for  a  part  of  the  day;  later  it  is  used  only  at  night; 
and,  finally,  it  may  be  discarded  if  the  child  walks  norm;illy. 
But  it  is  best  to  continue  the  daily  manipulation,  more  particu- 
larly the  systematic  stretcliing  or  overcorrection  of  the  foot,  for  a 
long  time.  Thus  one  may  assure  one's  self  that  there  is  no  ten- 
dency toward  deformity,  of  which  the  first  symptom  is  always 
a  slieht  limitation  of  dorsal  flexion  and  of  abduction. 


780  ORTHOPEDIC  SURGERY 

In  many  instances  the  deformity  may  haye  been  so  thoroughly 
oyercorrected  by  the  plaster-of-Paris  bandage  or  by  the  brace, 
and  the  after-treatment  of  massage  and  stretcliing  may  haye  been 
so  efl&ciently  appUed  by  the  nurse  or  parent,  that  the  retention 
brace  may  be  unnecessaiy.  On  the  other  hand,  the  inclination 
toward  deformity  may  be  so  marked  that  a  brace  may  be  neces- 
sary'- to  hold  the  foot  in  slight  abduction  and  yalgus  for  a  year 
or  longer.  In  other  cases  the  use  of  a  light  brace  to  hold  the 
foot  in  the  overcorrected  position  during  the  night  is  alone  required. 
These  are  points  to  be  decided  by  the  circumstances  in  each  case. 
The  period  of  obseryation  and  superyision  is  included  in  the  final 
stage  of  the  treatment. 

Third  Stage  of  Treatment.  Supervision. — During  tliis  period 
the  attitudes  of  the  limb  and  foot  of  the  walking  cliild  must  be 
carefully  watched,  and  particularly  the  signs  of  wear  on  the  sole 
of  the  shoe.  If  it  shows  greater  wear  on  the  outer  side  than  is 
usual  it  is  an  indication  that  the  weight  does  not  fall  directly  on 
the  centre  of  the  foot,  and  that  there  is,  therefore,  a  tendency 
toward  deformity.  This  must  be  counteracted  by  making  the 
sole  thicker  on  the  outer  side  or  slightly  wedge-shaped,  so  that 
the  weight  may  be  deflected  toward  the  inner  border. 

This  third  period  of  treatment,  or,  rather,  of  "oyersight  of  the 
functional  use  of  the  foot,  must  be  continued  indefinitely.  In 
fact,  it  is  the  quality  of  this  final  supervision  that  decides  in  most 
instances  whether  the  ultimate  outcome  is  to  be  what  is  called  a 
satisfactory  result  or  a  perfect  anatomical  and  functional  cure. 

The  Treatment  of  Neglected  Club-foot. — ^The  treatment  of 
club-foot,  under  what  may  be  called  the  proper  conditions,  as  out- 
lined in  the  preceding  pages,  applies  practically  to  all  cases  before 
the  completion  of  the  first  year  of  life,  and  mechanical  rectifica- 
tion may  be  successfully  employed  in  cases  far  beyond  this  limit 
of  age.  As  a  nde,  however,  when  the  patient  has  walked  for 
any  length  of  time,  the  resistance  of  the  tissues  has  increased 
to  such  an  extent  that  more  rapid  and  effective  treatment  is  indi- 
cated. The  investigations  of  Wolff  have  shown  that  the  internal 
structure  of  the  bones  corresponds  to  their  external  contour,  and 
that  the  structure  and  contour  are  adaptations  to  functional  use. 
This  internal  structure  is  not,  however,  permanent,  but  is  readily 
transformed  to  conform  to  changes  in  form  or  function.  If, 
then,  the  external  contour  of  the  club-foot  were  suddenly  reversed, 
and  if  the  foot  were  used  in  this  new  attitude,  a  transformation 
of  the  internal  structure  of  the  bones  and  at  the  same  time  of 


DEFORMITIES  OF  THE  FOOT  781 

their  shape  would  begin  at  once.  This  would  continue  until 
both  structure  and  shape  had  become  adapted  to  habitual  func- 
tion. It  is  upon  this  natural  power  of  transformation  that  one 
depends  for  the  final  and  complete  change  of  the  distorted  bones 
to  the  normal;  and  what  is  true  of  a  resistant  structure  like 
bone  is  equally  true  of  the  other  constituents  of  the  deformed 
foot. 

Age  as  Influencing  Treatment. — There  is,  then,  this  important 
difference  between  the  indications  for  treatment  in  infancy  and 
in  childhood.  In  the  first  instance  the  foot  has  no  essential 
function;  in  the  second  the  weight  of  the  body  and  habitual  use 
tend  to  confirm  and  to  increase  the  deformity.  If  walking  is 
permitted  during  the  process  of  rectification  of  the  foot  it  must 
necessarily  retard  its  progress.  As  a  general  principle  of  treat- 
ment, functional  use  should  not  be  permitted,  therefore,  until  the 
weight  of  the  body  may  aid  rather  than  retard  the  correction  of 
deformity.  The  great  numbers  of  complicated  and  cumbersome 
machines  that  are  described  in  the  older  text-books  were  designed 
for  the  ambulatory  treatment  of  club-foot;  and  admitting  that 
such  apparatus  may  be  efficacious  in  the  hands  of  one  skilled  in 
its  use,  yet  under  ordinary  conditions  treatment  by  such  means 
simply  serves  to  fix  rather  than  to  correct  the  deformity.  The 
most  important  function  of  the  brace,  aside  from  its  use  as  a 
correcting  appliance  in  early  infancy,  is  to  support  the  foot  after 
deformity  has  been  corrected  and  to  guide  it  in  its  functional  use 
until  its  normal  strength  has  been  regained.  And  while  rectifi- 
cation of  deformity,  even  in  adolescence,  by  simple  mechanical 
means  alone  is  possible,  yet  only  in  exceptional  cases  would  one 
be  justified  in  selecting  a  tedious  and  uncertain  treatment  which 
offers  practically  no  advantage  over  more  rapid  methods. 

The  Rapid  Correction  of  Deformity. — The  principles,  on  which 
operative  treatment  should  be  conducted  are  the  same  that  govern 
mechanical  treatment.  Thus,  the  deformed  foot  must  be  over- 
corrected,  and  it  must  be  held  in  the  overcorrected  position  until 
the  immediate  tendency  toward  deformity  has  been  overcome. 
It  must  then  be  supported  until  the  process  of  transformation  of 
its  internal  structure  is  completed  and  until  the -balance  of  mus- 
cular power  has  been  regained.  No  surgical  operation,  however 
radical,  can  be,  in  childhood  at  least,  curative  by  itself  alone. 
Operative  procedures  are  undertaken  simply  for  the  purjwse  of 
accomplishing  the  primary  overcorrection,  and  the  operation 
by  which  this  object  can  be  attained  with  the  least  interference 


782  ORTHOPEDIC  SURGERY 

with  the  structure  of  the  foot  should  be  selected.     Such  an  opera- 
tion is  what  may  be  called  forcible  manual  correction. 

Forcible  Manual  Correction. — The  patient  having  been  anres- 
thetized,  one  first  attempts  to  correct  the  sharp  inward  t-s\ist  at 
the  mediotarsal  joint.  Supposing  the  left  foot  to  be  deformed, 
one  grasps  the  heel  ^^'ith  the  right  hand  in  such  a  manner  that 
the  projection  or  muscular  part  of  the  palm  lies  on  the  outer 
aspect  of  the  foot  against  the  most  prominent  part  of  its  outer 
border,  which  is  at  the  junction  of  the  os  calcis  and  cuboid  bones. 
This  hand  ser\'es  as  a  fulcrum  over  which  the  inverted  foot  may 


Fig.  510 


Reduction  of  the  varus  deformity.   (Lorenz.) 

be  bent.  The  forefoot  is  then  grasped  firmly  by  the  left  hand, 
and  one  begins  a  series  of  outward  twists  over  the  fulcrum  of  the 
opposing  palm,  gently  at  first,  with  alternate  relaxation  of  pressure, 
but  with  gradually  increasing  force  as  the  resistant  tissues  stretch 
under  the  tension. 

If  greater  force  is  required,  a  triangular  block  of  wood,  well 
padded,  may  be  used  as  the  fulcrum  (Fig.  510),  one  hand  pressing 
cm  the  heel  and  the  other  on  the  forefoot;  but  there  is  a  great 
advantage  in  using  nothing  but  the  hands,  because  one  feels 
that  no  injurious  force  is  likely  to  be  exerted.     Under  this  steady 


DEFORMITIES  OF  TEE  FOOT 


783 


manipulation  the  foot  soon  loses  its  rigidit}'  and  its  elastic  recoil 
toward  deformity;  it  becomes  so  limp  that  with  two  fingers  one 
cannot  only  hold  the  sole  straight,  but  can  push  it  or  bend  it 
outward.  This  completes  the  first  stage  of  the  methodical  cor- 
rection. 

One  then  turns  liis  attention  to  the  inversion  of  the  sole,  which 
makes  the  outer  border  of  the  foot  lower  than  the  inner  border. 
The  leg  is  grasped  firmly  near  the  ankle  with  the  left  hand,  and 
with  the  right  the  foot  is  forcibly  twisted  in  a  direction  downward, 


Fig.  511 


Flattening  the  sole.     (Lorenz.) 

outward,  and  upward,  over  and  over  again,  with  steadily  increasing 
force  as  the  tissues  slowly  yield,  until  it  may  be  forced  into  a  posi- 
tion of  extreme  abduction,  so  that  the  sole  may  be  made  to  look 
outward  and  downward — the  reverse  of  the  former  attitude  (Fig. 
422). 

One  next  stretches  the  contracted  plantar  fascia  and  reduces 
the  cavus  which  is  usually  present  by  forcing  the  forefoot  toward 
dorsiflexion,  against  the  resistance  of  the  contracted  tendo  Achillis, 
until  the  sole  is   made   perfectly  flat   (Fig.   511).     Finally,   the 


784 


OB  THOPEDIC  S  UB  GEB  Y 


fourth,  and  often  the  most  difficult  part  of  the  rectification — that 
of  forcing  the  displaced  astragalus  into  its  proper  position  between 
the  malleoli — is  attempted.  To  accomplish  this  the  tendo  Achillis 
is  first  di\ided  subcutaneously,  and,  if  necessary,  the  posterior 
ligament  of  the  ankle  is  also  di%'ided  at  the  same  time.  The 
patient  is  then  turned  upon  his  face  so  that  with  the  knee  resting 
on  the  table  the  leg  is  held  upright.  This  allows  one  to  hook  the 
fingers  about  the  extremity  of  the  os  calcis,  while  the  hand  and 
arm,  lying  along  the  sole  of  the  foot,  may  be  used  as  a  lever  to 


Fig.   512 


Reduction  of  the  equinus  deformity.     (Lorenz.) 

force  it  toward  dorsal  flexion  as  the  os  calcis  is  drawn  down- 
ward. In  this  manner  forcible  stretching  is  continued  until  the 
dorsum  of  the  foot  can  be  brought  almost  into  apposition  with 
the  crest  of  the  tibia.  When  the  operation  has  been  completed 
the  foot  should  be  perfectly  limp.  It  is  usually  somewhat  con- 
gested from  the  pressure  of  the  fingers,  but  it  is  warm  and  the 
circulation  is  unimpaired. 

One  may  a.ssume  that  in  the  ti'ansformation  rigid  deformity 
to  yielding  tissues  can  be  moulded  into  the  desired  shape,  the 
component   parts   of   the   deformed   foot   must    have  been  sub- 


DEFORMITIES  OF  THE  FOOT  785 

jected  to  considerable  violence;  that  ligaments  and  muscles 
must  have  been  stretched  and,  it  may  be,  ruptured;  that  new 
surfaces  are  now  apposed  to  one  another  in  the  articulations, 
and  that  the  bones  have  been  forced  into  approximately  normal 
position.  This  method  of  treatment  has  a  great  advantage 
over  the  ordinary  operative  treatment  in  that  the  entire  foot  par- 
ticipates in  the  correction  instead  of  a  limited  portion,  as  when, 
for  example,  bone  is  removed  by  cuneiform  osteotomy.  It  has 
a  second  and  almost  equally  important  advantage  in  that  the 

Fig.   513 


Untreated  club-foot,  showing  the  secondary  knock-knee.      (See  Fig.   514.)     .       " 

immediate  use  of  the  corrected  and  yielding  foot  is  possible  in 
the  place  of  the  necessary  rest  that  must  follow  cutting  opera- 
tions. For  these  reasons  forcible  massage  should  be  the  operation 
of  choice,  and  preliminary,  at  least,  to  more  severe  procedures 
in  the  treatment  of  resistant  club-foot  in  cliildhood.  The  only 
disadvantage  of  the  operation  is  the  actual  labor  which  it  neces- 
sitates on  the  part  of  the  surgeon,  usually  twenty  minutes  or 
more  of  rather  exhausting  work. 

The  foot  must  now  be  fixed  by  a  plaster  bandage  in  an  over- 
corrected   position.     It  is  first   evenly  covered   with  a   layer  of 

50 


786 


ORTHOPEDIC  SURGERY 


cotton,  and  while  it  is  held  by  the  assistant  the  plaster  bandages 
are  applied  from  the  tips  of  the  toes  to  the  upper  part  of  the  thigh. 
It  is  important  that  the  toes  should  not  project  beyond  the  bandage 
because  of  the  swelling  that  sometimes  follows.  It  is  important, 
also,  that  the  foot  should  be  held  in  the  proper  position  while  the 
bandage  is  hardening,  and  that  it  should  not  be  manipulated  to 
any  extent  after  the  bandage  is  applied,  in  order  that  no  rigid 
\sTinkle  may  press  against  the  skin.  The  bandage  is  applied  above 
the  knee  in  order  that  the  tibia  may  be  rotated  outward  to  its 


Fig.  514 


Fig.   515 


After  forcible  correction.     Compare  with 
Fig.  513. 


The  attitude  of  overcorrection,  in  which 
the  feet  are  fixed  after  the  operative  treat- 
ment, the  plaster  bandage  extending  only 
to  the  knees. 


normal  position  and  held  there,  and  because  more  effective  fixation 
may  be  assured  and  greater  pressure  exerted  on  the  foot  in  walk- 
ing. To  utilize  this  pressure  to  better  advantage  the  bandage 
should  be  made  very  thick  beneath  the  sole,  and  a  thin  foot-plate 
of  wood  may  be  incorporated  in  the  plaster  if  due  care  is  taken 
to  prevent  pre.ssure  on  sensitive  points.  When  the  bandage  is 
applied  the  foot  should  be  flexed  beyond  the  right  angle,  twisted 
far  (jiitward,  and  the  outer  border  should  be  elevated  considerably 
beyond  the  level  of  the  inner  border  (Fig.  514). 


DEFORMITIES  OF  THE  FOOT  787 

One  would  suppose  that  much  pain  and  swelling  would  follow 
the  operation.  This  is,  however,  not  usually  the  case.  Often,  on 
the  following  day,  the  patients  are  able  to  stand  upon  the  foot, 
and  always  within  the  first  week  if  the  bandage  has  been  properly 
applied.  The  pain  following  this  operation  is  far  more  often 
caused  by  pressure  of  an  ill-fitting  bandage  than  by  the  violence 
that  has  been  used.  Thus  one  should  be  careful  to  remove 
sections  of  the  bandage  if  it  appears  to  cause  undue  discomfort. 
These  points  are  usually  the  front  of  the  ankle,  the  back  of  the 
heel,  and  the  inner  border  of  the  great  toe. 

The  Importance  of  Functional  Use. — ^The  immediate  use  of  the 
foot  is  encouraged,  in  order  that  the  weight  of  the  body  falling 
on  its  yielding  structure  may  still  further  correct  the  deformity. 
Although  only  the  heel  and  inner  border  bear  weight  directly, 
yet  the  pressure  of  the  plaster  sole  on  the  parts  that  do  not  come 
in  contact  with  the  floor  is  usually  sufficient  to  mould  the  foot 
into  its  proper  shape.  If  greater  pressure  is  thought  to  be  neces- 
sary, wedges  of  wood  or  cork  may  be  attached  to  the  sole  of  the 
plaster  bandage,  so  that  all  parts  may  bear  weight  equally.  The 
bandage  is  covered  by  a  stocking;  a  slipper  may  be  worn  in-doors 
and  an  ordinary  overshoe  for  street  wear. 

The  first  bandage  should  be  removed  at  the  end  of  about  four 
weeks,  as  it  will  have  become  loose.  The  foot  will  then  be  found 
to  be  extremely  flexible,  and  by  an  enthusiast  it  might  be  consid- 
ered cured;  but  knowledge  of  its  previous  condition  should  make 
it  evident  that  a  much  longer  time  will  be  necessar}^  to  allow 
for  its  consolidation  in  the  new  position.  At  this  time  almost 
no  CA^dence  of  the  operation  remains  except,  it  may  be,  slight 
discoloration  of  the  sldn.  The  foot  is  again  held  as  far  as  possible 
in  the  overcorrected  position  and  another  plaster  bandage  is 
applied,  usually  as  far  as  the  knee  only.  Tliis  is  allowed  to  remain 
for  from  six  weeks  to  six  months,  according  to  the  character  of  the 
deformity  and  quality  of  the  after-treatment,  it  being  apparent,  of 
course,  that  the  longer  the  foot  is  fixed  in  the  overcorrected  posi- 
tion the  less  danger  of  subsequent  relapse.  The  patient  uses  the 
foot  constantly  and  is  drilled  in  the  proper  method  of  walking, 
so  that  the  muscles  of  the  limbs  may  become  accustomed  to  the 
new  and  normal  attitudes. 

In  most  instances  the  plaster  bandage  is  replaced,  at  ti  e  end 
of  about  three  months,  by  a  brace  to  be  worn  inside  the  shoe, 
usually  of  the  simplest  description  (Fig.  531),  consisting  of  an 
upright  bar  with  a  calf  band,  attached  to  a  steel  sole  plate  by  a 


788 


ORTHOPEDIC  SURGERY 


Fig.    516 


joint  that  will  permit  dorsal  flexion  but  checks  extension  at  a 
right  angle.  This  is  applied  because  the  dorsal  flexors,  after 
years  of  disuse,  only  slowly  recover  sufficient  power  to  resist  the 
action  of  the  opposing  group  and  the  influence  of  gra\'ity. 

The  second  stage  of  the  treatment  is  now  begun.  This  may 
be  diM'ded  into  a  period  of  active  treatment  and  one  of  super- 
vision. The  first,  or  treatment- 
stage,  consists  in  massage  of  the 
entire  leg  and  of  the  foot  to  stimu- 
late the  growth  of  the  atrophied 
muscles,  and  methodical  manipula- 
tion of  the  foot  several  times  a  day. 
The  important  point  in  this  manip- 
ulation is  to  force  the  foot  with  the 
hand  to  the  extreme  limit  of  the  range 
of  motions  possible  immediately  after 
the  operation,  viz.,  eversion,  abduc- 
tion, and  dorsal  flexion,  in  the  same 
order  as  at  the  time  of  operation. 
At  the  same  time  the  patient  attempts 
voluntarily  to  carry  out  these  motions 
with  his  own  muscles,  the  power 
being  supplied  by  the  hand  of  the 
manipulator.  Slowly  the  muscles 
gain  in  strength  and  ability,  and 
when  normal  muscular  power  and 
balance  have  been  regained,  the 
patient  is  practically  cured.  But  for 
a  long  period,  supervision  of  the 
patient's  attitude,  of  the  manner  of 
using  the  foot,  of  the  wear  of  the 
sole  of  the  shoe  and  the  like  must 
be  exercised  if  one  aims  to  restore  its 
normal  appearance  and  function. 
One  cannot  exaggerate  the  importance  of  this  after-treatment, 
and  of  supervision  at  least,  on  the  part  of  the  surgeon.  The 
active  treatment  may  often  be  left  to  the  parents.  But  constant 
oversight  is  necessary  to  make  this  after-treatment,  which  seems 
so  commonplace  and  simple,  effective,  and  to  assure  one's  self 
that  the  range  of  motion  regained  by  the  operation  does  not  grad- 
ually Vjecome  more  and  more  restricted,  even  though  the  contour 


The  Taylor  club-foot  brace,  with 
pelvic  band,  to  prevent  inward  rota- 
tion of  the  leg.  The  brace  is  shown  be- 
fore the  covering  and  straps  are  applied. 


DEFORMITIES  OF  THE  FOOT  789 

of  the  foot  appears  to  be  normal.  Forcible  manual  correction  may 
be  employed  with  advantage  from  the  second  to  the  tenth  year, 
although  the  limits  may  be  extended  in  either  direction  in  special 
cases.  In  tb's  operation,  as  described,  the  tendo  Achillis  is  the 
only  structure  divided.  There  is  no  particular  objection  to  subcu- 
taneous division  of  other  tendons  or  lio-aments  in  connection  with 
forcible  manual  correction;  but  for  such  prolonged  manipulation  it 
is  much  better  if  the  skin,  which  itself  must  be  stretched,  is  un- 
broken and  dry  rather  than  moist  from  the  bleeding  from  punctured 
wounds.  For  this  reason  it  is  well  to  correct  the  deformity  without 
tenotomy  if  possible.^ 

Secondary  Deformities. — In  cases  such  as  have  been  described 
secondary  distortions  of  the  limb  are  often  present.  Knock- 
knee  rarely  requires  other  treatment  than  daily  manual  correc- 
tion in  connection  with  the  massage  of  the  foot  and  leg.  Hyper- 
extension  at  the  knee  will  correct  itself  during  the  treatment  of 
the  foot,  which,  being  fixed  in  an  attitude  of  dorsal  flexion,  obliges 
the  patient  to  bend  the  knee  habitually  in  walking.  Inward 
rotation  of  the  leg  upon  the  thigh  is  often  present.  This  may  be 
overcome  by  methodical  manipulation  and  by  the  use  of  a  brace 
attached  to  a  pelvic  band  (Fig.  516). 

In  many  instances,  particularly  in  cliildhood  and  adolescence, 
the  patient  has  so  long  walked  with  exaggerated  outward  rotation 
of  the  femur  that  after  correction  of  the  deformity  no  inward 
rotation  of  the  foot  appears,  even  though  inward  rotation  of  the 
tibia  be  present.  In  other  cases  the  inward  rotation  of  the  foot 
is  caused  by  a  failure  to  completely  replace  the  astragalus  between 
the  malleoli.  Occasionally  the  tibia  is  actually  twisted  on  its 
long  axis,  so  that  an  osteotomy  may  be  required  in  order  to  over- 
come the  deformity. 

Malleotomy. — In  confirmed  club-foot,  of  the  type  under  con- 
sideration, the  chief  obstacle  to  perfect  correction  is  often  the 
astragalus.  Tliis  is  displaced  forward,  downward,  and  inward, 
only  the  posterior  portion  of  its  articulating  surface  being  con- 
tained between  the  malleoli.  Thus  the  space  between  the  two 
bones  may  have  become  insufficient  for  the  anterior  and  wider 
part  of  the  body  of  the  astragalus.  In  such  cases,  even  after 
division  of  the  tendo  Achillis  and  the  posterior  ligament  of  the 

'  Forcible  manual  correction  appears  to  have  been  described  first  by  Delore.  Lorenz  em- 
ploys the  method  supplemented  in  the  older  cases  by  the  use  of  his  osteoclast,  to  the  exclu- 
sion, practically,  of  all  other  treatment.  (Hcilung  des  Klumpfusses  durch  das  modellirende 
Redressement,  Wiener  Klinik,  November,  1895.)  For  this  reason  it  is  sometimes  calleil  the 
Lorenz  treatment.  The  method  that  has  been  described  has  been  employed  by  the  author 
for  many  years. 


790  ORIHOPEDIC  SUBGEBY 

ankle,  dorsal  flexion  still  remains  restricted,  and  examination 
shows  that  the  astragalus  still  projects  as  before,  even  though  the 
foot  has  been  forced  into  a  position  of  apparent  dorsiflexion  and 
abduction.  This  apparent  correction  is  the  result  of  overcorrec- 
tion at  the  mediotarsal  joint,  of  outward  rotation  of  the  tibia  upon 
the  femur,  and  of  backward  displacement  of  the  fibula. 

In  such  instances  the  malleoli  may  be  separated  from  one 
another  by  di\iding  the  ligaments  that  hold  them  in  apposition. 
A  straight  incision  about  two  inches  long  is  made  directly  over 
the  anterior  aspect  of  the  articulation,  the  ligaments  are  divided, 
and  by  inserting  a  thin  cliisel  the  bones  are  pried  apart,  while 
the  astragalus  is  replaced  in  the  proper  position.  This  is  usually 
easy  if  the  restraining  tissues  on  the  posterior  part  of  the  ankle 
have  been  divided.  The  wound  is  then  closed  and  the  foot  held  in 
the  overcorrected  position  by  a  plaster  bandage.  Complete  cor- 
rection of  the  varus  deformity  should,  of  course,  precede  this 
operation. 

It  might  seem  on  first  consideration  that  if  immediate  correc- 
tion  of  deformity  can  be  accomplished  so  easily  in  the  confirmed 
cases  it  should  be  employed  even  in  infancy.  There  are,  how- 
ever, practical  reasons  against  it :  First,  because  the  foot  is  so 
small  that  it  cannot  be  easily  manipulated;  second,  because  even 
after  it  is  corrected  it  must  be  supported  until  the  child  begins 
to  walk;  and  third,  because  the  foot  .can  be  so  readily  straightened 
without  operation,  which,  even  of  so  slight  a  character,  is  some- 
times the  cause  of  much  anxiety  to  the  parents.  For  these  reasons, 
although  immediate  reduction  of  deformity  is  a  practicable  opera- 
tion, it  is  usually  postponed  until  a  later  time. 

Subcutaneous  Tenotomy. — The  division  of  tendons  and  other 
tissues  by  the  subcutaneous  method  has  been  mentioned  incident- 
ally, but  as  it  has  so  long  occupied  an  important  and  even  at  one 
time  the  most  important  place  in  the  treatment  of  club-foot,  the 
operation  and  its  effects  may  be  described  somewhat  in  detail. 

Tenotomy,  as  has  been  stated,  is  performed  for  the  purpose  of 
removing  an  obstacle  to  the  correction  and  overcorrection  of 
deformity.  In  the  acquired  or  paralytic  form  of  talipes  one 
or  more  shortened  tendons  may  be  the  chief  obstacles  to  reposi- 
tion; h)ut  in  the  congenital  form,  in  which  all  the  tissues  have 
grown  into  deformity,  the  shortened  tendons  are  by  no  means  the 
only  resistant  parts,  and  tenotomy  should  be  considered,  there- 
fore, merely  as  an  incident  in  cf)rrection.  In  the  ordinary  treat- 
ment of  infantile  club-foot  tenotomy  is  usually  unnecessary  and  in 


DEFORMITIES  OF  THE  FOOT  791 

the  great  majority  of  cases  division  of  the  tendo  Achillis  is  alone 
required. 

When  the  tendon  has  been  divided  the  deformity  is  immedi- 
ately overcorrected;  thus  the  two  extremities  are  separated  to 
the  extent  necessary  to  allow  the  improved  position.  At  the  end 
of  three  weeks  or  more,  or  at  the  time  when  the  first  plaster 
bandage  is  removed,  the  space  will  be  filled  with  new  material, 
and  in  another  month  the  splice,  which  will  be  somewhat  larger 
and  thicker  than  the  normal,  should  be  strong  enough  for  use. 
The  slight  thickening  at  the  site  of  the  operation  may  be  felt  for 
a  year  or  more,  but  for  all  intents  and  purposes  the  new  and 
lengthened  tendon  is  perfectly  normal,  as  is  the  function  of  the 
muscle  of  which  it  is  a  part. 

The  process  of  repair  is  somewhat  as  follows:  Immediately 
after  the  operation  the  space  between  the  divided  ends  of  the 
tendon  is  filled  or  partially  filled  with  blood;  then  leukocytes 
appear,  which,  with  those  in  the  blood  clot,  serve  as  pabulum 
for  the  plasma  cells  which  migrate  from  between  the  fasciculi  of 
the  tendon  and  from  the  tendon  sheath.  The  fibrin  and  red  cor- 
puscles of  the  clot  are  absorbed;  the  extremities  of  the  divided 
tendon  soften  and  become  fused  with  the  new  material,  which 
begins  to  take  on  the  form  and  consistency  of  true  tendon  and 
to  separate  itself  from  the  adherent  sheath.  This  new  tendon 
differs  from  the  normal  structure  in  that  the  fibrous  fasciculi 
are  more  irregular  and  its  substance  is  more  like  scar  tissue,  but 
practically  it  is  normal  in  its  appearance  and  function.^ 

Since  the  tendon  sheath  serves  an  important  purpose  in  repair, 
it  should  be  disturbed  as  little  as  possible.  For  this,  as  well  as 
for  other  obvious  reasons,  subcutaneous  tenotomy  of  the  tendo 
Achillis,  which  is  so  prominent  and  so  distinct  from  other  impor- 
tant parts,  is  to  be  preferred;  but  if  more  extensive  division  of 
other  tendons  is  required  the  open  operation  is  often  indicated. 

Division  of  the  Tendo  Achillis. — For  this  operation  anaesthesia 
is  usually  required,  preferably  by  means  of  nitrous  oxide  gas;  and 
it  is  hardly  necessaiy  to  state  that  surgical  cleanliness,  even  in 
so  slight  a  procedure,  is  essential. 

The  instrument  should  be  small  and  very  sharp,  so  that  no 
force  is  required  in  the  operation;  the  blade  should  be  as  long  as 
the  tendon  is  wide.  The  patient  is  turned  upon  the  side  or  to 
the  prone  position,  so  that  the  foot  may  be  held  with  the  heel 

>  R.  Seggel,  Beitr^e  sur  klin.  Chir.,  1903,  Band  xxxvii.,  S.  342. 


792  ORTHOPEDIC  SURGERY 

upward  by  the  left  hand.  The  position  and  size  of  the  tendon 
is  ascertained  by  careful  palpation,  and  the  knife  is  then  inserted 
to  its  inner  side,  at  about  the  level  of  the  extremity  of  the  internal 
malleolus.  The  flat  surface  of  the  blade  is  held  parallel  to  the 
tendon,  and  it  is  passed  beneath  it  until  its  point  can  be  felt  beneath 
the  skin  on  the  opposite  side.  The  edge  is  then  turned  upward 
and  the  tendon,  being  made  tense,  is  di^ided  by  a  sawing  motion 
of  the  knife.  When  the  division  is  complete,  as  indicated  by 
the  separation  of  the  divided  ends,  the  knife  is  withdrawn,  and 
the  minute  opening  in  the  skin,  from  which  there  is  usually  slight 
bleeding,  is  covered  with  a  pledget  of  aseptic  cotton.  The  foot 
is  forced  into  dorsal  flexion  and  is  securely  fixed  by  a  plaster 
bandage.  In  applying  the  dressing  one  should  take  care  that 
no  pressure  is  brought  upon  the  seat  of  operation,  as  this  might 
interfere  with  the  effusion  of  plastic  material.  As  soon  as  the 
discomfort  attending  the  operation  has  subsided  the  patient  is 
encouraged  to  stand  and  to  walk.  Functional  use  stimulates  the 
circulation,  and,  far  from  retarding  repair,  it  is  in  my  experience 
an  important  agent  in  assuring  firm  and  rapid  union. 

The  Open  Method. — The  tendon  may  be  exposed  by  a  long 
vertical  incision;  it  is  then  split  for  a  distance  of  two  or  three 
inches,  and  the  division  is  completed  at  the  upper  and  lower  ends. 
The  two  halves  are  then  allowed  to  slide  by  one  another  until 
the  necessary  elongation  has  been  obtained.  These  are  then 
sutured  to  one  another. 

Theoretically,  this  operation,  which  assures  union  at  a  point 
of  selection,  is  safer  than  the  subcutaneous  method,  in  which  the 
ends  of  the  tendon  are  separated  from  one  another;  practically, 
it  is  in  this  class  of  cases  less  satisfactory  in  its  results  than  the 
subcutaneous  method. 

Division  of  the  plantar  fascia  is  often  necessary.  The  tenotome 
is  inserted  beneath  the  skin  at  about  the  centre  of  the  concavity 
to  one  or  the  other  side  of  the  central  band  of  the  fascia,  which  is 
divided  by  a  sawing  motion  of  the  knife.  The  part  is  put  upon 
the  stretch,  and  other  resisting  bands  to  the  outer  and  inner  side 
are  divided  in  the  same  manner;  the  cavus  is  then  corrected  by 
manual  oi'  instrumental  force. 

Division  of  the  tibialis  anticus  is  not  often  necessary,  as  this 
tendon  offers  little  resistance  to  the  rectification  of  deformity  of 
the  ordinary  type. 

The  tendon  of  the  tibialis  posticus  may  be  divided  together 
with  that  of  the  tibialis  anticus  near  the  points  of  attachment. 


DEFORMITIES  OF  THE  FOOT  793 

If  the  operation  is  required  it  may  be  combined  with  simulta- 
neous section  of  the  calcaneonavicular  ligament,  with  which  are 
blended  the  anterior  part  of  the  deltoid  and  fibres  of  the  anterior 
ligament  of  the  ankle.  According  to  Parker's  directions,  the  foot 
should  be  strongly  abducted  to  make  the  parts  tense.  The  teno- 
tome is  entered  directly  in  front  of  the  anterior  border  of  the  internal 
malleolus,  its  cutting  edge  being  turned  forward  between  the  skin 
and  the  ligament.  It  is  then  turned  toward  the  ligament,  and 
the  tissues  are  divided  to  the  bone.  The  blade  is  then  made  to 
enter  the  interval  between  the  astragalus  and  the  scaphoid,  and 
is  carried  downward  and  forward  to  divide  the  inferior  part  of 
the  ligament  and  at  the  same  time  the  tendons  of  the  tibialis 
anticus  and  posticus. 

The  posterior  ligament  of  the  ankle-joint  may  be  divided  or 
sufficiently  weakened  so  that  it  may  be  ruptured  after  section  of 
the  tendo  Achillis  by  passing  the  knife  directly  downward  in  the 
middle  line  upon  the  upper  border  of  the  astragalus. 

The  Correction  of  Confirmed  Club-foot  by  the  Method  of 
JuUus  Wolff. 

Wolff's  treatment  of  club-foot,  as  described  by  Freiberg,  a 
former  assistant  in  his  clinic,  may  be  summarized  as  follows:^ 
The  patient  is  anaesthetized,  and  with  the  hands  and  by  the  use 
of  a  moderate  amount  of  force  the  deformity  is  reduced  as  far  as 
possible.  The  foot  is  held  in  the  improved  position  by  means  of 
strips  of  adhesive  plaster  passing  from  the  dorsal  surface  of  the 
inner  border  of  the  foot  under  the  sole  and  up  to  the  outer  aspect 
of  the  leg.  The  leg  and  foot  are  then  covered  with  cotton  from 
the  tuberosity  of  the  tibia  to  the  tips  of  the  toes,  and  a  plaster 
bandage  is  applied.  As  the  plaster  is  hardening  the  position  of 
the  foot  is  still  further  improved  by  pressing  the  heel  inward  and 
the  forefoot  outward  and  upward.  Two  fenestra  are  cut  in  the 
plaster  at  the  points  of  greatest  pressure — one  over  the  external 
surface  of  the  ankle  and  the  other  over  the  internal  surface  of 
the  great  toe.  If  tenotomy  is  considered  necessary  it  is  usually 
performed  as  a  preliminary'  operation  several  days  before  forcible 
correction. 

On  the  third  or  fourth  day  after  the  operation  a  wedge-shaped 
section  is  cut  from  the  bandage  on  the  outer  side  of  the  ankle- 
joint  and  a  linear  division  is  made  about  the  ankle,  so  that  the  leg 

1  Medical  News.  October  29,  1892. 


794 


ORTHOPEDIC  SURGERY 


Fig.  517 


and  the  foot  parts  of  the  bandage  are  separated  (Fig.  517).  The 
leg  being  held  firmly,  the  foot  is  forced  outward  and  upward  to 
the  extent  that  the  wedge-shaped  opening  on  the  plaster  will 
allow,  and  the  two  sections  are  then  united  by  a  covering  of  plaster 
bandage.  For  the  secondary  correction  anaesthesia  is  not  required. 
At  intervals  of  several  days  larger  wedges  are  removed,  and  the 
manipulation  is  repeated  until  the  patient  stands  with  the  foot 
in  a  satisf actor}'  attitude;  that  is,  in  pronation,  abduction,  and 
dorsiflexion.  If  the  deformity  is  extreme  the  bandage  may  be 
reapplied  before  the  correction  is  com- 
pleted with  ad\antage.  One  should  take 
care  that  the  toes  are  not  compressed,  but 
lie  on  the  same  plane  in  normal  relation 
to  one  another. 

When  rectification  is  complete  the  plaster 
bandage  is  covered  with  strips  of  pine  shav- 
ings, held  in  place  by  a  crinoline  bandage, 
and  painted  with  carpenter's  glue.  When 
this  is  hardened  the  whole  is  covered  with  a 
thin  silicate  bandage;  over  this  the  shoe  is 
fitted  and  the  patient  is  encouraged  to  walk. 
This  form  of  dressing  is  used  until  the  trans- 
formation of  the  deformed  parts  may  be  sup- 
posed to  be  complete,  the  time  varying  with 
the  case,  from  a  few  months  to  a  year.  The 
time  required  for  the  primary  correction  is 
from  a  week  to  a  month.  When  the  bandage 
is  finally  removed  massage  and  exercises  are 
to  be  employed.^  Wolff's  treatment  is  an  efficient  means  of  correc- 
tion, although  somewhat  tedious.  It  may  be  more  conveniently  em- 
ployed in  later  childhood  and  adolescence  than  at  an  earlier  age. 


THe  points  at  which  the 
bandage  is  divided  and  the 
wedge  removed.  (Freiberg.) 


Forcible  Correction  of  Deformity  by  Means  of  Osteoclasts 
and  Wrenches. 

In  place  of  manual  correction  greater  force  may  be  employed 
by  means  of  wrenches  or  osteoclasts  to  overcome  the  deformity. 
There  is  this  important  difference  between  the  two  procedures: 
force  may  be  applied  by  the  hands  for  as  long  a  time  as  is  necessary 
without  fear  of  injury,  while  force  applied  by  a  machine  must  be 


'  Ueber  fiie  UrHachcn,  dun  Wcsteii  iiiid  die  Behandluiig  des  Klumpfuswes. 
Berlin,   1905. 


Julius  Wolff, 


DEFORMITIES  OF  THE  FOOT 


795 


momentary  because  of  the  pressure  and  strain  on  the  parts  where 
the  leverage  is  exerted.  Manual  force  continuously  applied  may 
be  supposed  to  stretch  the  resistant  parts,  and  although  much 
less  power  is  exerted  it  is  really  more  effective  than  the  sudden 
and  momentary  force  of  the  wrench  or  osteoclast,  because  it 
may  be  continued  until  the  deformity  has  been  overcorrected, 
while  complete  correction  by  means  of  instruments  may  nec-es- 
sitate  several  operations. 


Fig.  518 


Fig.   519 


The  Thomas  wrench  as  used  in  the 
correction  of  club-foot. 


Resistant  club-foot  in  later  chililhooil, 
(See  Fig.  521.) 


The  Thomas  Method. — Of  instrumental  correction  that  by 
means  of  the  Thomas  wrench  is  one  of  the  simplest  and  most 
efficient.  The  wrenching  may  or  may  not  be  preceded  by  ten- 
otomy, a  point  to  be  decided  by  the  resistance  of  the  parts.  As 
a  rule,  division  of  the  tendo  Achillis  alone  is  necessary.  The 
instrument  is  a  simple  heavy  monkey-wrench,  of  which  the  jaws 
have  been  replaced  by  two  strong  pins  slightly  bulbous  at  the 
ends  to  keep  the  covers  of  rubber  tubing  from  slipping  off. 


796  OB THOPEDIG  SUB  GEB  Y 

The  T\Tencli  is  applied  to  the  inner  side  of  the  foot  and  screwed 
down  so  that  it  may  "bite"  and  hold  its  place  firmly,  for  if  it 
slips  it  is  likely  to  abrade  or  tear  the  skin;  then  with  consider- 
able force  the  foot  is  twisted  outward  and  upward  (Fig.  518). 
The  "keynote"  of  the  operation  is  to  so  wrench  the  foot  that 
it  loses  its  elasticity  and  shows  no  tendency  to  recoil  toward  defor- 
mity. The  foot  is  then  placed  in  the  best  possible  position,  and 
is  retained  there  by  the  Thomas  foot  splint  or  by  a  plaster  bandage. 
In  certain  instances  one  may  complete  the  rectification  at  one 
operation,  but  this  is  not  usually  attempted,  the  procedure  being 
repeated  at  inten'als  of  a  few  days  until  the  deformity  has  been 
overcorrected.  In  very  resistant  cases  eight  or  ten  applications 
of  force  may  be  necessary.  When  the  deformity  has  been  rec- 
tified the  foot  is  held  in  the  overcorrected  position  for  several 
weeks  by  the  splint  or  by  the  plaster  bandage. 

As  a  walking  appliance  a  simple  upright  of  iron  with  a  calf 
band  is  applied  to  the  inner  side  of  the  leg,  from  a  point  just 
below  the  knee  to  the  heel  of  the  shoe  into  which  it  is  inserted, 
as  is  the  Thomas  knock-knee  brace  (Fig.  376).  By  bending  the 
upright  the  foot  may  be  held  in  slight  valgus,  and  this  position 
is  still  further  assured  by  making  the  outer  side  of  the  sole  of 
the  shoe  thicker  than  the  inner,  so  that  the  weight  falls  upon  the 
inner  border  of  the  foot.  In  many  instances  the  walking  brace 
may  be  dispensed  with  in  the  after-treatment,  but  a-  light  brace 
is  usually  worn  to  hold  the  foot  in  the  corrected  position  during 
the  night,  until  the  power  of  the  abductors  and  dorsal  flexors  has 
been  regained.  Massage  and  manipulation  are  used  in  the  after- 
treatment  in  the  manner  already  described. 

When  properly  applied  the  treatment  is  satisfactory  and  free 
from  danger.  Sloughing  of  the  tissues  caused  by  the  pressure 
of  the  instrument  or  by  the  plaster  bandages  has  been  reported, 
but  such  accidents  have  not  occurred  in  the  extensive  practice  of 
Thomas  and  Jones. 

Correction  by  Means  of  the  Osteoclast. — The  late  Mr. 
Grattan,  of  Cork,  used  the  osteoclast  that  goes  by  his  name 
(Fig.  380)  to  crush  and  to  overcorrect  resistant  club-foot.  The 
operation  may  include  besides  the  correction  of  the  deformitjyof 
the  foot  itself,  fracture  of  the  leg  above  the  malleolus,  to  turn  the 
foot  toward  valgus,  and  a  second  fracture  half-way  up  the  leg, 
to  overcome  the  inward  rotation  or  twist  of  the  tibia.  Mr. 
Grattan's  results  have  been  very  satisfactory.  Other  appliances 
constructed  on  somewhitt   similar   principles   may  be  employed. 


DEFORMITIES  OF  THE  FOOT 


797 


Of  these  the  Lorenz  osteoclast^  and  the  Bradford'  lever  apparatus 
are  the  most  effective. 

The  Open  Incision  Combined  with  Forcible  Rectification  of 
Deformity.  Phelps'  Operation. — When  extensive  division  of 
contracted  parts  is  indicated  the  open  incision  is  to  be  preferred 
because  of  the  opportunity  thus  offered  for  the  recognition  and 
for  intelligent  selection  of  structures  that  require  division  in  the 
final  correction  of  the  deformity. 

Phelps'  operation  is  essentially  simply  the  division  of  resistant 
parts  through  an  incision  on  the  inner  border  of  the  foot,  com- 
bined with  sufficient  force,  manual  or  instrumental,  to  overcorrect 


Fig.   .520 


lllustraliug  the  correctioa  of  the  left  foot  by  Phelps'  operation. 

the  deformity.  It  is  the  most  conservative  of  the  more  radical 
procedures,  and  by  it  even  the  most  severe  type  of  deformity  in 
the  adult  can  be  corrected;  that  is  to  say,  the  deformity  may  be 
overcome  and  a  semceable  foot  may  be  assured  to  the  patient. 
Perfect  functional  cure  is  not  possible  when  deformity  has  been 
confirmed  by  many  years  of  neglect. 

The  steps  of  the  Phelps'  operation  are  as  follows :  After  proper 
surgical  preparation  the  Esmarch  bandage  is  applied.  The  tendo 
Acliillis  and  usually  the  posterior  ligaments  of  the  ankle  are 
divided  subcutaneously,   and   by   manual  or  instrumental  force 


'  Wiener  Klinik,  November,  December,  1895.        -  Bradford  and  Lovett,  2d  ed.,  p.  414. 


798 


ORTHOPEDIC  S UB GEB Y 


one  attempts  to  correct  the  plantar  flexion.  An  incision  is  then 
made  on  the  inner  border  of  the  foot,  just  below  and  in  front  of 
the  internal  malleolus,  which  is  extended  directly  downward  over 
the  head  of  the  astragalus  to  include  the  inner  quarter  of  the  sole. 
Through  the  incision  all  resistant  parts  are  di^'ided  in  order,  as 
stated  by  Phelps. 

1.  The  tibialis  posticus,  and  the  anticus  if  it  offers  resistance. 

2.  The  abductor  hallucis. 

3.  The  plantar  fascia. 

4.  The  flexor  bre\is  digitorum. 

5.  The  long  flexor  of  the  toes. 

6.  The  deltoid  ligament  in  all  its  branches. 

Fig.   521 


Tlio  left  fout  (Fig.  519)  corrected  by  Phelps'  operation  and  by  cuneiform  osteotomy 

of  the  OS  calcis. 

During  the  successive  division  of  the  tissues  repeated  attempts 
are  made  to  correct  the  foot,  and  only  those  structures  are  divided 
that  present  thf'rnselv(;s  as  tense  and  resistant  tissues  when  the 
foot  is  forcibly  abducted. 

In  the  adult  type  of  club-foot  no  particular  effort  is  made  to 
recognize  the  different  struc-tures,  but  all  the  tissues  on  the  inner 
side  of  the  fo(jt,  including  bloodvessels  and  nerves,  the  deep  liga- 


DEFORMITIES  OF  THE  FOOT 


799 


ments,  and  occasionally  the  tendon  of  the  peroneus  longus  muscle, 
are  divided.  Even  then  it  is  necessary  to  apply  considerable 
force  to  correct  the  deformity.  In  certain  instances  the  recti- 
fication of  deformity  necessitates  osteotomy  of  the  neck  of  the 
astragalus  or  the  removal  of  a  cuneiform  section  from  the  os  calcis. 
The  object  of  the  Phelps  operation  is,  by  division  of  resistant 
tissues  and  by  the  use  of  force,  to  overcorrect  the  deformed  foot 
at  one  sitting,  and  as  much  force  and  as  extensive  division  of 


Fig.   522 


Resistant  club-foot  in  later  childhooil.     (See  Fig.  523.) 


tissues  as  are  required  to  accomplish  this  object  should  be  employed 
by  the  operator. 

When  the  foot  can  be  held  in  the  desired  position  without 
resistance  the  wound  is  covered  with  Lister  protective,  the  foot 
and  leg  are  thickly  covered  with  gauze  and  cotton,  a  plaster 
bandage  is  applied,  and  the  limb  is  elevated.  The  large,  gaping 
wound  closes  by  granulation  in  from  one  to  three  months.  The 
first  bandage  is  usually  changed  at  the  end  of  one  or  two  weeks, 
and  the  patient  then  begins  to  bear  weight  on  the  foot. 

By  this  operation  the  foot,  even  in  severe  cases  in  adult  life. 


800  OB  THOPEDIC  S UB GEB  Y 

may  be  made  straight  in  appearance.  It  is  evident,  however, 
that  in  such  cases  the  correction  of  the  deformity  of  the  bones  is 
by  no  means  always  perfect,  for  the  forefoot  may  be  simply 
twisted  outward  and  upward,  while  the  astragalus  and  os  calcis 
may  remain  in  an  approximation  to  their  original  deformity. 
After  thorough  overcorrection  by  the  Phelps  operation  the  danger 
of  recurrence  of  deformity  in  the  adult  and  adolescent  type  of 
club-foot  is  not  great,  and  in  many  instances  support  other  than 
that  of  the  plaster  bandage  for  several  months  after  the  operation 
may  be  unnecessary;  but  in  childhood  the  ordinary  precautions 
in  after-treatment  to  prevent  relapse  will  be  necessary. 

Operations  on  the  Bones. 

Osteotomy  of  the  neck  of  the  astragalus,  as  a  supplementary 
part  of  the  operation  of  forcible  correction,  has  been  mentioned. 
In  certain  instances,  particularly  in  the  adolescent  or  adult  type 
of  deformity,  the  displaced  astragalus  may  offer  such  an  obstacle 
to  correction  that  its  removal  is  indicated — an  operation  first 
performed  by  Mr.  Lund,  of  Manchester. 

Astragalectomy. — The  astragalus,  which  in  club-foot  is  displaced 
forward,  may  be  removed  easily  by  means  of  an  incision  passing 
over  its  most  prominent  part,  in  a  direction  forward  and  down- 
ward from  the  tip  of  the  external  malleolus,  between  the  tendons  of 
the  peroneus  brevis  and  tertius.  The  soft  parts  are  drawn  aside, 
the  ankle  and  astragalonavicular  joint  are  opened,  and  the  attach- 
ments to  the  navicular,  and,  as  far  as  possible,  those  at  the  inner 
and  outer  border,  are  divided.  The  foot  is  then  adducted  so 
that  the  head  of  the  bone  may  be  seized  with  forceps  and  drawn 
upward,  the  interosseous  ligament  and  the  internal  lateral  liga- 
ment having  been  divided  with  curved  scissors,  the  astragalus 
is  removed.  If  after  removal  of  the  astragalus  the  deformity 
cannot  be  corrected,  the  anterior  part  of  the  os  calcis  or  the 
external  malleolus  should  be  removed  as  well.  A  useful  movable 
foot  may  be  obtained  by  this  operation,  but  it  by  no  means  assures 
the  patient  from  recurrence  of  deformity.  It  is  never  indicated 
as  a  primary  operation,  in  childhood  at  least.  The  varus  should 
be  thoroughly  corrected  as  a  preliminary  procedure,  for  until 
then  the  resistance  that  the  astragalus  offers  to  dorsal  flexion 
cannot  be  a(rcura(ely  estimated  (Fig.  523), 

Cuneiform  Osteotomy. — The  removal  of  cuneiform  sections 
of  bone  from  the  outer  border  of  the  foot  is  sometimes  indicated 


DEFORMITIES  OF  THE  FOOT 


801 


when  the  deformity  is  of  long  standing,  but  the  operation  should 
be  secondary  to  other  methods  of  correction.  The  aim  should  be 
to  lengthen  the  contracted  and  shortened  tissues  on  the  inner 
border  of  the  foot  to  the  extent  required  for  reposition,  not  to 
remove  bone  to  accommodate  these  shortened  tissues.  If  this 
has  been  shown  to  be  impossible  by  ordinary  means,  then  re- 
moval of  bone  may  be  indicated;  but  it  is  not  often  necessary  in 
childhood  or  even  in  adolescence.  If  sufficient  bone  is  cut  away 
from  the  adult  foot  to  permit  complete  correction  of  the  defor- 


FiG.  523 


Fig.   524 


After  forcible  correctioa  and  astraga- 
lectomy.     (See  Fig.  523.) 


Partially  corrected  club-foot,  showing 
secondary  knock-knee. 


mity,  relapse  is  not  usual;  but  in  childhood,  as  has  been  stated, 
no  operation  will  take  the  place  of  after-treatment. 

The  treatment  by  cuneiform  osteotomy  as  it  is  ordinarily  car- 
ried out  is  sufficiently  simple.  In  severe  cases  the  astragalus  is 
usually  removed,  and  a  wedge-shaped  section  of  bone  is  taken  from 
the  OS  calcis,  cuboid,  and,  if  necessary,  it  may  include  the  navicular 
bone  also.  The  external  malleolus  may  be  removed  if  it  inter- 
feres with  reposition.  Preliminaiy  fasciotomies  and  tenotomies 
are  usually  performed,  but  those  who  favor  this  method  of  treat- 

51 


802  OB  THOPEDIC  S  UB GEB  Y 

ment  rarely  use  force  in  reposition.  If  the  deformity  is  less 
marked  the  astragalus  is  not  removed,  but  a  part  of  its  body  and 
neck  are  included  in  the  cuneiform  resection.  The  foot  is  retained 
in  proper  position  until  the  wounds  are  closed;  then  plaster 
bandages  are  employed  for  several  months.  Braces  are  seldom 
used  in  the  after-treatment. 

Secondary  Osteotomy. — In  certain  cases  of  relapsed  or  in- 
effectively treated  club-foot,  even  in  childhood,  deformity  of  the 
OS  calcis  interferes  with  correction  of  the  foot.  In  such  instances 
the  removal  of  a  cuneiform  section  of  bone  from  the  anterior 
extremity,  may  be  of  ser\dce.  Osteotomy  of  the  tibia  may  be 
required  in  cases  of  persistent  inward  rotation. 

Simple  Mechanical  Rectification  of  Deformity  in  Walking 
Children  and  in  Later  Years. 

It  has  been  stated  that  simple  mechanical  rectification  of  de- 
formity was  possible  even  in  adolescence,  but  that  the  time  re- 
quired for  such  treatment,  usually  extending  over  several  years, 
as  a  rule,  excluded  it  from  consideration. 

The  simplest  mechanical  treatment  is  that  by  which  the  foot  is 
slowly  forced  from  equinovarus  into  equinovalgus  by  a  brace  on 
the  lever  principle,  which  is  at  first  shaped  to  the  deformity,  and 
is  then  gradually  straightened  as  the  resistance  diminishes.  When 
the  midpoint  has  been  passed  between  varus  and  valgus  the 
weight  of  the  body  aids  in  the  correction  of  the  remaining  varus 
and  equinus.  The  modification  of  the  Taylor  brace  used  by  Jud- 
son,  an  advocate  of  pure  mechanics  in  the  treatment  of  club-foot, 
will  serve  to  illustrate  the  type  of  apparatus  which,  with  slight 
change,  may  be  employed  to  correct  or  to  support  the  weakened 
or  deformed  foot. 

The  brace  consists  of  an  upright,  a  flat,  tapering  bar  of  mild 
steel,  a  foot-plate  of  steel  from  18  to  16  gauge,  and  a  strong  calf 
band.  The  shape  of  the  brace,  the  method  of  its  attachment  to 
the  leg  by  straps  of  webbing,  and  its  effect  in  gradually  changing 
the  attitude  of  the  foot  from  varus  to  valgus  are  shown  in  the 
accompanying  figures. 

The  upright  is  firmly  riveted  to  the  foot-plate  in  the  angle  of 
deformity,  so  that  the  patient  must  walk  upon  his  toes;  as  the 
equinus  is  decreased  by  the  influence  of  the  weight  of  the  body 
this  angle  is  lessened  (Figs.  527  and  531). 

The  impfjrtant  points  are  that  the  brace  shall  be  strong  enough 


DEFORMITIES  OF  THE  FOOT 


803 


to  hold  its  place  under  the  strain  of  use  and  that  the  foot  shall 
be  firmly  secured  to  it,  whether  one  or  many  straps  of  webbing 
are  required,  as  may  be  seen  in  the  figures.  The  use  of  massage 
and  manipulation  is,  of  course,  combined  with  the  mechanical 
treatment. 

By  persistent  attention  to  the  details  of  treatment  satisfactory 
results  can  be  obtained  occasionally  by  this  method  in  the  less 
resistant  cases,  even  in  adolescence. 


Fig.  52.5 


Fig.  526 


The  Judson  brace.  Fig.  525  shows  the  construction  of  the  brace;  the  foot-plate,  with 
internal  flange  or  "riser,"  the  upright  riveted  to  it,  and  the  calf  band.  Fig.  526  shows  the 
brace  adjusted  to  fit  the  deformed  foot. 

Recapitulation  of  the  Principles  of  Treatment  of  Congenital 
Talipes  Equinovarus. — The  object  of  treatment  is  to  overcome 
and  to  overcorrect  the  deformity  at  as  early  a  period  of  life  as 
is  possible,  and  as  quickly  as  possible.  The  object  of  overcorrec- 
tion is  to  overcome  all  the  resistance  of  the  tissues  that  may  even 
in  the  slig-htest  degree  limit  the  normal  range  of  motion  in  any 
direction.  The  foot  must  be  fixed  in  the  overcorrected  posi- 
tion until  the  recoil  of  the  tissues  toward  deformity  is  no  longer 
present. 

It  must  be  supported  in  the  proper  relation  to  the  leg,  and 
at  a  rig-ht  angle  with  it,  until  the  muscular  balance  has  been 
re-established  by  stimulation  of  the  weaker  and  by  limitation  of 


804 


ORTHOPEDIC  SURGERY 


the  actmty  of  the  stronger  muscles,  and  until  transformation  of 
the  internal  structure  has  been  completed. 

If  efficient  mechanical  treatment  is  applied  at  the  proper  time 
— ^that  is  to  say,  in  earliest  infancy — no  operation  other  than 
dinsion  of  the  tendo  Achillis  will  be  required. 

If  the  deformity  is  not  corrected  or  is  but  partially  corrected 
when  the  child  begins  to  walk,  some  form  of  operation  is,  as  a 
rule,  indicated;  but  di\ision  of  the  resistant  tissues  must  always 


Fig.  527 


Fig.  528 


Fig.  529 


Showing  the  progressive  reduction  of  deformity.  Fig.  527  shows  the  ordinary  attitude  of 
the  neglected  club-foot  in  childhood  with  the  adjustment  of  the  brace,  it  being  bent  to 
accommodate  the  deformity.  Fig.  528  shows  additional  details — an  upright  spur,  useful  in 
holding  the  heel  and  for  the  attachment  of  straps;  the  spur  of  .sheet  brass  that  may  be  bent 
over  the  great  toe  to  hold  it  in  position.  Fig.  529  shows  other  details  in  the  method  of 
attachment,  a  strip  of  adhesive  plaster,  with  two  tails  in  the  place  of  the  band  of  webbing. 
This  aids  in  fixing  the  heel.     (See  Figs.  530  and  531.) 

be  combined  with  the  employment  of  sufficient  force  to  accom- 
plish the  desired  result,  viz.,  overcorrection  of  the  deformity. 
Forcible  manual  correction,  applied  in  the  manner  described,  is 
the  most  efficient  means  of  attaining  this  object.  No  instrument 
can  equal  the  hand.  The  force  that  can  be  applied  by  the  hand 
is  sufficient  for  the  correction  of  all  the  ordinary  cases  in  early 
childhood,  and,  in  combination  with  subcutaneous  division  of  the 
mcjre  resi.stant  tendons  and  ligaments,  even  in  later  childhood  and 
adolescence. 


DEFORMITIES  OF  THE  FOOl 


805 


Forcible  correction  by  the  Thomas  wrench  under  the  same 
conditions  is  an  efficient  treatment,  but  there  is  a  manifest  disad- 
vantage in  submitting  a  patient  to  a  succession  of  operations, 
even  of  so  slight  a  character,  if  immediate  overcorrection  can  be 
attained  by  other  means. 

The  Phelps  operation,  which  combines  thorough  division  of  the 
resistant  parts  with  the  application  of  sufficient  force  to  overcorrect 
the  foot,  is  the  operation  of  selection  for  the  more  resistant  cases 
in  adolescence,  in  adult  life,  and  in  extremely  resistant  cases  in 
childhood. 


Fig.  530 


Fig.  531 


Showing  the  progressive  reduction  of  deformity  and  illustrating  the  process  of  changing 
the  shape  of  the  brace  from  time  to  time  until  it  holds  the  foot  in  valgus.     (See  Fig.  527.) 

Astragalectomy  and  cuneiform  osteotomy  are  never  indicated 
as  primary  operations,  but  one  or  the  other  may  be  necessary  for 
the  complete  rectification  of  the  deformity  when  other  means  have 
failed. 

Complete  cure  of  deformit),  even  in  the  later  years  of  cln'ld- 
hood,  is  possible  by  means  of  braces  alone,  but  such  treatment  is 
very  tedious.  It  requires  the  continuous  supervision  of  the  skilled 
orthopedist,  as  well  as  the  intelligent  and  persistent  co-operation 
of  the  parents.     The  results  are  in   no   way  superior  to  those 


806  ORTHOPEDIC  SURGERY 

attained  by  more  rapid  methods,  while  the  disadvantages  of  long 
continued  use  of  braces  are  suflScientlj  obvious.  To  the  popular 
faith  in  braces  as  a  cure-all  of  deformitv,  and  to  the  unintelligent 
use  of  braces,  may  be  ascribed  now,  as  in  former  times,  the 
greater  number  of  failures  in  treatment  of  this  eminently  curable 
deformity.  On  the  other  hand  the  belief,  so  prevalent  among 
physicians,  that  a  radical  operation,  if  it  does  not  absolutely 
assure  a  cure,  is,  at  least,  the  essential  part  of  the  treatment  is 
equally  falacious. 

Rectification  of  deformity,  by  whatever  means,  simply  com- 
pletes the  first  stage  of  treatment.  Perfect  cure  can  only  be 
assured  by  attention  to  the  small  details  of  after-treatment,  by 
checking  the  slightest  impulse  toward  deformity,  and  by  guiding 
the  unbalanced  foot  toward  normal  functional  use. 

Other   Varieties  of  Congenital  Talipes. 

Forms  of  congenital  distortion  of  the  foot  other  than  equino- 
varus  are  not  uncommon;  but,  as  a  rule,  these  deformities  are  so 
slio-ht  and,  as  compared  to  equinovarus,  so  easily  remedied  that 
they  are  relatively  of  little  importance.  This  distinction  does 
not  apply,  however,  to  acquired  talipes,  which  will  be  considered 
in  the  succeeding  chapter. 

Congenital  Talipes  Varus. — Eighty-nine  cases  of  simple  varus 
are  recorded  in  the  table  of  statistics  in  a  total  of  2103  congenital 
deformities  of  the  foot. 

This  deformity  often  appears  to  be  an  incomplete  form  of 
equinovarus,  but  in  some  instances  there  is  simply  a  slight  inward 
twist  of  the  foot  without  supination  (Fig.  470).  In  some  cases  of 
this  character,  the  forefoot  is  apparently  drawn  inward  by  the 
active  movement  of  the  great  toe,  which,  in  such  cases,  seems 
almost  prehensile.  (See  Pigeon-toe.)  In  the  more  marked  form 
the  foot  is  adducted  and  supinated,  and  the  tissues  are  veiy  re- 
sistant. 

The  slight  grades  of  deformity  may  be  treated  by  simple  manip- 
ulation, and  if  distortion  persists  after  the  first  year  the  shoe 
will,  as  a  rule,  correct  it.  The  more  marked  varieties  must  be 
treated  like  the  varus  deformity  of  ordinary  club-foot,  by  braces 
or  by  the  plaster  bandage,  until  the  varus  has  been  transformed 
into  valgus.  The  after-treatment  is  the  same  as  that  for  ordinary 
club-foot. 


DEFORMITIES  OF  THE  FOOT  807 

Congenital  Talipes  Eqninus.^ — This  is  a  rare  congenital 
deformity,  about  half  as  common,  according  to  the  statistics,  as 
varus  (49  cases  in  2103).  The  term  equinus  implies  that  dorsal 
flexion  is  limited,  but  that  the  foot  is  not  deviated  to  one  or  the 
other  side  (toward  valgus  or  varus).  In  congenital  equinus  the 
deformity  is,  as  a  rule,  slight,  and  in  many  instances  it  may  be 
overcome  by  gentle  manual  force  applied  frequently.  In  the 
more  resistant  type  mechanical  correction  or  tenotomy,  followed 
by  overcorrection  and  support,  may  be  necessary. 

Congenital  Talipes  Calcaneus. — Congenital  calcaneus  is  com- 
paratively rare  (47  cases  in  2103).  As  a  rule,  the  heel  is  promi- 
nent, the  foot  is  habitually  dorsiflexed,  and  the  dorsum  can 
be  easily  brought  into  contact  with  the  crest  of  the  tibia  (Fig. 
485).  The  exaggerated  cavus  that  is  usually  present  in  acquired 
calcaneus  is  absent.  Occasionally  the  deformity  is  accompanied 
by  hyperextension  of  the  knee;  and  if,  as  in  many  instances,  there 
is  a  history  of  breech  presentation,  it  may  be  inferred  that  the 
attitude  before  birth  was  one  of  extreme  flexion  of  the  thighs 
upon  the  abdomen,  the  anterior  surfaces  of  the  extended  legs 
being  pressed  closely  to  the  ventral  surface  of  the  body,  the  feet 
being  fixed  in  an  attitude  of  dorsiflexion.  As  a  rule,  the  defor- 
mity  is  slight,  and  the  resistance  of  the  tissues  on  the  anterior  aspect 
of  the  leg  can  be  easily  overcome  by  massage  and  manipulation. 
The  foot  should  be  gently  forced  toward  plantar  flexion  several 
times  in  the  day,  and  the  weak  muscles  of  the  calf  should  be 
stimulated  by  massage. 

Cure  may  be  hastened  by  the  use  of  some  simple  form  of  reten- 
tion splint  to  hold  the  foot  in  plantar  flexion  until  the  posterior 
group  of  muscles  has  recovered  its  power.  Tenotomy  or  other 
operative  treatment  is  not  often  required. 

In  rare  instances  the  tibia  may  be  bent  slightly  backward, 
thus  increasing  the  deformity.  In  such  cases  the  distortion  of 
the  bone  may  be  overcome  by  manipulation  and  by  apparatus. 

Congenital  Talipes  Valgus. — Congenital  valgus  (Fig.  486)  is 
somewhat  more  common  than  the  preceding  varieties  (144  in 
2103).  Not  infrequently  it  is  combined  with  a  slight  degree  of 
calcaneus  or  equinus.  The  resistance  of  the  contracted  tissues 
is  not  great,  and  the  deformity  may  be  overcome,  in  most  cases, 
by  persistent  manipulation.  If  the  muscular  power  is  suflficiently 
unbalanced  to  warrant  it  the  foot  should  be  fixed  in  the  over- 
corrected  position  (varus)  for  a  time. 

Congenital   valgus  is  one  form  of    what  is  known    as  weak 


808 


ORTHOPEDIC  SURGERY 


ankle,  and  it  frequently  passes  unnoticed  until  the  child  begins 
to  walk.  If  at  that  time,  in  spite  of  massage,  the  muscles  appear 
weak  or  if  the  foot  inclines  outward  when  weight  is  borne  it  is 
well  to  make  the  sole  of,  the  shoe  wedge-shaped,  the  thicker  part 
(one-quarter  of  an  inch)  on  the  inner  side.  In  more  persistent 
cases  a  brace  may  be  necessary,  as  described  in  the  treatment  of 
the  acquired  variety.     (See  Weak  Foot.) 

Talipes  EquinovalgUS  is  less  common  (35  in  2103).    Tliis  must 
be  treated  as  the  other  varieties    by  complete  overcorrection  of 

Fig.  532 


Congenital  calcaneovalgus. 


deformity,    manual   or   otherwise,    and    by   subsequent   massage 
and  support  if  necessaiy. 

Calcaneovalgus  (87  in  2103),  Calcaneovarus  (10  in  2103), 
Equinocavus  (1  in  2103),  Valgocavus  (1  in  2103),  Cavus  (5  in 
2103),  are  extremely  rare,  as  indicated  by  the  statistics.  If  treated 
early  by  persistent  massage  supplemented  by  retention  apparatus, 
these,  as  well  as  nearly  all  slighter  grades  of  congenital  defor- 
mity, may  be  corrected  and  cured  even  before  the  child  begins 
to  walk. 


DEFORMITIES  OF  THE  FOOT 


809 


Congenital   Deformities   of   the    Foot  Associated  with 
Defective  Development. 

Talipes  Equinovalgus  Associated  with  Congenital  Absence 
of  the  Fibula. ^ — This  is  a  rare  deformity,  but  the  most  common  of 
this  class.  The  foot  at  birth  is  usually  in  an  attitude  of  well- 
marked  and  resistant  equinovalgus.  The  leg  is  somewhat  shorter 
than  its  fellow,  and  the  tibia  is  often  bent  sharply  forward,  some- 
times to  an  acute  angle,  at  a  point  somewhat  below  the  centre,  as 

Fig.  533 


Congenital  equinovarus,  with  deformity  of  the  great  toes. 


if  it  had  been  broken.  At  the  most  prominent  point  the  skin 
may  be  adherent  or  it  may  present  a  dimpled  appearance.  In 
some  instances  the  formation  of  the  foot  is  perfect,  but  more 
often  one  or  more  of  the  outer  toes,  with  the  corresponding  meta- 
tarsal bones,  are  absent  (Fig.  534). 

Statistics. — Haudek  collected  from  the  literature  97  cases.  Of 
these  46  were  in  males,  21  were  in  females,  and  in  30  the  sex 
was  not  recorded.  In  07  (69  per  cent.)  there  was  total  absence  of 
the  fibula.  In  30  the  defect  was  partial;  of  the  lower  extremity 
of  the  fibula  in  17,  of  the  upper  extremity  in  9,  and  of  the  middle 


810 


OBTHOPEDIC  SURGERY 


Fig.  534 


in  2  cases.  In  27  cases  both  fibulae  were  absent  or  defective; 
in  68  one  only — ^the  right  in  31,  the  left  in  25,  and  in  the  others 
the  side  was  not  recorded.  In  61  cases  toes  were  lacking,  and 
in  these  cases  it  may  be  inferred  that  the  corresponding  meta- 
tarsal bones  were  absent  also. 
The  fourth  and  fifth  toes  were 
absent  in  27  cases;  the  little  toe 
alone  was  missing  in  15.  In 
many  instances,  as  is  usual  in 
cases  of  defective  development, 
deformity  of  other  parts  was 
present;  for  example,  in  17  in- 
stances the  patella  was  absent  or 
undeveloped  and  in  11  the  upper 
extremities  were  defective.^ 

Etiology. — The  cause  of  de- 
formity, associated  with  absence 
of  bone,  may  be  either  an  origi- 
nal defect  in  the  germ  or  it  may 
be  due  to  interference  with 
its  development.  In  some  in- 
stances amniotic  adhesions  may 
be  one  of  the  predisposing 
causes;  the  sharp  bend  in  the 
tibia,  so  often  present,  may  be 
due  to  the  lessened  resistance 
of  the  defective  part. 

Treatment.  —  The  indica- 
tions for  treatment  are  to  cor- 
rect the  deformity  of  the  foot  in 
the  usual  manner.  The  bend 
in  the  tibia  may  be  straightened 
by  manipulation  and  splinting, 
or  by  osteotomy  if  necessary. 
When  the  patient  begins  to  walk 
the  foot  must  be  supported.  A 
light  steel  upright  on  the  outer  side  of  the  leg,  provided  with  a 
T-strap  to  hold  the  leg  against  it,  will  supply  the  place  of  the 
missing  fibula.     As  the  growth  of  the  tibia,  and  in  less  degree  that 

•  Cotton  and  Chute,  Boston  Medical  and  Surgical  Journal,  1898,  No8.  8  and  9  (128  cases). 
Mazzitelli,  Arch.  Ortopedia,  1898,  F.  5.  Boinet,  Revue  d'Orthop^die,  November,  1899.  Vide 
also  Emil  Hain  (113  cases),  Archiv.  Orthop.  Mechanicotherapie  und  Unfal  Chir.,  1903,  Bd.  i. 
H.  1. 


Defective  formation  of  the  lower  limb,  illus- 
trating progressive  disproportion. 


DEFORMITIES  OF  THE  FOOT  811 

of  the  femur,  is  retarded  a  final  shortening  of  three  or  more  inches 
may  be  expected,  but  with  care  a  useful  limb  may  be  assured. 

Talipes  Varus  or  Equinovarus  Associated  with  Congenital 
Absence  of  the  Tibia. — Defective  formation  of  the  tibia  is  much 
less  common  than  that  of  the  fibula.  Myers^  has  collected  46  cases . 
Of  the  38  cases  in  which  the  sex  was  recorded,  25  were  in  males  and 
13  in  females.  In  31  instances  the  defect  was  of  one  side;  in  17  both 
tibiae  were  defective.  In  most  of  the  cases  the  femur  was  somewhat 
shortened  and  its  lower  extremity  was  imperfectly  developed.  In  a 
third  of  the  cases  the  patella  was  absent,  and  in  many  instances 
other  malformations  were  present.  In  nearly  all  the  cases  there  was 
flexion  contraction  at  the  knee  and  the  fibula  was  dislocated  back- 
ward. The  foot  is  practically  always  in  an  attitude  of  varus.  The 
toes  may  be  normal,  but  in  a  number  of  instances  the  great  toe 
is  lacking.  In  possibly  a  tliird  of  the  cases  a  portion  of  the  tibia, 
usually  the  upper  extremity,  is  present.^ 

The  prognosis  as  regards  a  useful  limb  is  extremely  bad.  The 
growth  of  both  the  thigh  and  the  leg  is  much  retarded,  and  it  is 
almost  impossible  to  balance  the  foot  upon  the  fibula  by  any  form 
of  brace. 

The  ordinary  treatment,  after  the  correction  of  the  deformity 
of  the  foot,  has  been  to  resect  the  extremities  of  the  femur  and  the 
fibula  to  induce  anchylosis.  No  final  results  have  been  reported, 
but  it  may  be  assumed  that  an  artificial  Hmb  would  provide  a 
more   useful    support  than   the   short   and    distorted    extremity. 

Congenital  Deficiency  and  Hypertrophy. — ^The  leg  bones  may 
be  perfectly  formed,  but  one  or  more  bones  of  the  foot  itself  may 
be  absent.  In  these  cases,  after  the  reduction  of  the  deformity, 
a  support  to  hold  the  defective  foot  in  its  proper  relation  to  the 
leg  must  be  used. 

The  foot  may  be  divided  into  two  parts,  so  that  it  resembles  a 
lobster  claw.  Supernumerary  toes,  or  deficiency  of  toes,  or  hyper- 
trophy of  one  or  more  of  the  toes,  with  or  without  corresponding 
overgrowth  of  the  foot  or  leg,  are  not  extremely  uncommon. 

These  deformities  must  be  treated  on  ordinary'  surgical  prin- 
ciples.^ 

^  Medical  Record,  July  15,  1905. 

-  Lanois  and  Kuss  report  40  cases.     Revue  d'Orthop^die,  November,  1901. 
'  Ueber  missbildungen  der  Menschilichen  Gliedmassen  und  ihre  entstehuugsweise,  Klaus- 
ner.  1900. 


812  ORTHOPEDIC  SUBOEBY 


Constricting  Bands. 

Tightly  constricting  bands  of  scar-like  tissue,  accompanied  by 
deep  indentations  in  the  flesh  of  the  foot  or  leg,  are  sometimes 
seen.  These  are  supposed  to  be  caused  by  amniotic  adhesions. 
"Spontaneous  amputations"  of  toes  or  of  the  foot  itself  are  due 
to  the  same  cause  (Fig.  489). 

In  ordinaiy  cases  the  bands  require  no  treatment,  but  if  they 
interfere  with  the  nutrition  of  the  foot  they  may  be  removed. 

Congenital  (Edema  of  the  Feet. 

In  rare  instances,  sometimes  in  combination  with  deformity, 
the  tissues  of  the  feet  appear  to  be  oedematous,  although  the  circu- 
lation seems  to  be  perfect.  The  condition  is  apparently  due  to 
obstruction  of  the  lymphatic  circulation. 

It  should  be  treated  by  massage  and  by  compression. 

Spina  Bifida  and  Talipes. 

Talipes  with  spina  bifida  should  be  treated  as  are  other  forms 
of  club-foot.  If  paralysis  of  the  lower  extremities  be  present, 
as  is  often  the  case,  the  corrected  feet  must  be  supported  as  in 
the  ordinary  forms  of  paralytic  deformity.^ 


CHAPTER    XXIII. 

DEFORMITIES   OF  THE   FOOT    (Continued). 
Acquired  Talipes. 

In  the  account  of  the  congenital  deformities  of  the  foot  it  was 
stated  that  the  form  known  as  equinovarus  was  by  far  the  most 
common,  and  that  as  compared  with  it  the  other  deformities  were 
of  slight  importance. 

In  the  acquired  varieties  of  talipes  the  equinovarus  deformity 
is  much  less  common,  the  proportion  in  the  congenital  form  being 
77.4  per  cent,  and  in  the  acquired  30  per  cent,  of  the  total  num- 
ber. Acquired  equinus  comes  next  in  frequency,  25.9  per  cent, 
as  compared  with  2.3  per  cent,  of  the  congenital  deformity;  and 
every  variety  and  combination  of  distortion  finds  its  representa- 
tive in  acquired  talipes,  as  may  be  seen  in  the  tables.  (See  page 
761.) 

Etiology. — ^The  cause  of  acquired  talipes  is  almost  always 
paralysis.  In  the  table  of  statistics  it  will  be  seen  that  in  79.9 
per  cent,  the  paralysis  was  of  spinal  origin  (anterior  poliomyelitis). 
In  11.5  per  cent,  it  was  cerebral,  the  talipes  being  a  part  of  the 
deformity  of  hemiplegia  or  paraplegia.  In  a  few  cases  the  de- 
formity was  caused  by  local  disease  or  by  local  paralysis,  and 
the  remainder,  or  7  per  cent.,  were  of  traumatic  origin. 

The  distinction  between  the  two  varieties  of  talipes,  congenital 
and  acquired,  has  already  been  emphasized.  In  the  congenital 
form  the  deformity  is  the  essential  disability,  for  when  deformity 
has  been  rectified  the  most  difficult  part  of  the  treatment  has 
been  accomplished  and  perfect  cure  may  be  expected.  In  the 
acquired  form  the  straightening  of  the  foot  is  but  a  preliminaiy 
part  of  the  treatment,  for  cure  is  not  to  be  expected  except  in 
that  small  proportion  of  cases  in  which  the  primarv  disease  of 
the  spinal  cord  has  caused  no  permanent  injury  to  its  structure, 
or  in  which  the  deformity  was  the  result  of  some  slight  or  pass- 
ing disability  or  of  disease  or  injury.  Congenital  talipes  cannot 
be  anticipated  or  prevented.  Acquired  talipes  is  an  eft'ect  of  par- 
alysis only  when  protective  treatment  has  been  neglected.     It  is  a 


h 


814  ORTHOPEDIC  SUBGEBY 

result,  therefore,  that  may  be  foreseen,  and  thus,  by  proper  treat- 
ment, prevented. 

Development  of  Deformity. — ^The  characteristics  of  anterior 
poliomyelitis  are  described  elsewhere.  (Chapter  XVII.)  In  its 
effect  upon  the  foot  the  usual  sequence  is  somewhat  as  follows: 
At  the  onset  the  paralysis  is  usually  widespread,  affecting  an 
entire  limb,  for  example;  then  follows  a  period  of  partial  recovery, 
after  which  the  amount  of  damage  that  the  spinal  cord  has  sus- 
tained may  be  estimated.  It  is  during  the  period  of  partial 
recover}',  the  six  months  or  more  following  the  attack,  that  deform- 
ity develops.  If,  for  example,  the  anterior  group  of  leg  muscles 
is  paralyzed,  the  foot  habitually  hangs  downward,  an  attitude 
induced  by  the  force  of  gravity  and  by  the  contraction  of  the 
unaffected  posterior  group.  If  it  is  allowed  to  persist  the  tissues 
accommodate  themselves  to  the  new  position;  the  active  mus- 
cles which  are  never  extended  to  their  normal  limit  become  struc- 
turally shortened,  while  the  weakened  or  paralyzed  muscles 
are  correspondingly  overstretched.  Even  within  a  few  weeks 
after  the  onset  of  the  paralysis  the  evidences  of  progressive  de- 
formity are  plain.  The  contracted  tissues  resist  passive  motion 
in  the  directions  opposed  to  the  habitual  attitude,  and  the  child 
shows  evidence  of  pain  if  force  is  used  to  increase  the  limited 
range  of  motion.  As  has  been  stated  already,  acquired  talipes 
is  an  unnecessary  deformity.  It  may  be  prevented  by  support- 
ing the  paralyzed  part  in  a  right-angled  relation  to  the  limb, 
and  by  systematic  passive  movements  throughout  the  entire  range 
of  normal  motions. 

Anterior  poliomyelitis  is  most  common  during  the  second  year 
of  life,  or  when  the  child  has  already  begun  to  walk.  When  the 
first  or  more  general  effect  of  the  disease  has  passed  away  the 
child  again  uses  the  disabled  limb  as  best  it  may;  thus  the  dis- 
tortion of  the  foot  is  increased  and  confirmed  by  the  weight  of 
the  body  and  by  functional  use  in  the  abnormal  attitude. 

The  final  deformity,  in  a  particular  case,  can  be  predicted  from 
a  knowledge  of  the  function  of  the  muscles  which  have  been  dis- 
abled. For  example,  paralysis  of  the  tibialis  anticus,  the  most 
powerful  dorsiflexor  and  invertor  of  the  anterior  group,  must 
result  in  equinovalgus.  If  the  peroneus  brevis  and  tertius  are 
affected  varus  will  follow.  Paralysis  of  the  calf  muscles  will 
cause  calcaneus.  Paresis  or  paralysis  of  the  entire  anterior  group 
will  cause  equinus.  If  all  the  muscles  are  paralyzed,  what  is 
called  a  dangle-foot  is  the  result;  the  cold,  atrophied j^member 


DEFORMITIES  OF  THE  FOOT  815 

dangles  with  but  little  tendency  to  deformity  unless  it  is  capable 
of  use,  when  it  is  usually  forced  into  an  attitude  of  varus  or 
valgus. 

A  slight  degree  of  paralysis  may  cause  so  little  immediate 
disability  that  it  may  be  overlooked,  and  yet  it  may  be  sufficient 
to  induce  disability  or  deformity  even,  in  later  years.  This  fact 
has  been  mentioned  in  the  etiolog}-  of  the  contracted  foot. 

Differential  Diagnosis  between  Congenital  and  Acquired 
Deformity. — The  histoiy  itself  usually  indicates  the  etiology,  for 
deformity  of  the  foot  at  birth  is  never  overlooked  by  the  mother. 
Acquired  talipes  is  of  slow  development,  and  it  is  practically 
always  preceded  by  disease,  weakness,  or  injur}^ 

In  paralytic  talipes  (anterior  poliomyelitis)  there  is  evidence  of 
paralysis  in  loss  of  function  of  certain  muscles,  as  shown  by  elec- 
trical stimulation  or  by  pricking  the  foot  with  a  pin;  later,  in  the 
atrophy  of  the  muscles  and  often  in  the  evident  change  in  the 
nutrition  and  diminished  growth  of  the  limb. 

Only  in  neglected  and  extreme  cases  of  talipes  in  the  adolescent 
or  adult  could  there  be  difficulty  in  distinguishing  between  the 
acquired  and  the  congenital  deformity.  In  rare  instances,  it  is 
true,  paralysis  may  be  present  at  birth,  due  to  intrauterine  dis- 
ease or  to  defect  in  the  nervous  apparatus.  In  such  cases  the 
cause  of  the  paralysis  is  usually  apparent  (spina  bifida  or  spastic 
paralysis  associated  with  defective  cerebral  development),  and 
the  treatment  does  not  differ  from  that  of  the  acquired  form. 

Acquired  Talipes   Equinus. 

In  well-marked  equinus  the  foot  is  plantar  flexed  to  its  full 
limit,  and  it  is  fixed  in  this  attitude  by  the  shortened  structures 
of  which  the  tendo  Achillis  is  the  most  important.  The  patient 
wallcs  upon  the  heads  of  the  metatarsal  bones,  the  toes  being 
dorsiflexed  to  accommodate  the  deformity.  The  arch  of  the  foot 
is  increased  in  depth  and  the  tissues  of  the  sole,  particularly  the 
plantar  fascia,  are  contracted.  The  foot  is  broadened  and  short- 
ened, the  breadth  being  especially  increased  at  the  anterior  meta- 
tarsal region  (Fig.  484).  Corresponding  to  the  exaggerated  depth 
of  the  arch,  the  dorsum  projects,  the  cuneiform  bones  are  promi- 
nent, and  the  head  and  body  of  the  displaced  astragalus  may  be 
felt  beneath  the  skin  on  the  anterior  surface  (^f  the  foot.  In  the 
slighter  degrees  of  the  deformity,  when  the  patient  still  walks 
upon  the  sole  of  the  foot,  the  toes  are  usually   dorsiflexed — an 


816 


ORTHOPEDIC  SURGERY 


attitude  due  apparently  to  the  overaction  of  the  extensor  longus 
digitorum  and  proprius  halkicis,  as  aids  in  dorsiflexion  (Fig.  535). 
In  rare  instances,  and  only  in  those  cases  in  which  all  the 
anterior  muscles  are  paralyzed,  the  toes  may  be  plantar  flexed 
the  patient  walking  upon  their  dorsal  surfaces. 

The  cavus  or  increased  depth  of  the  arch  is  due  primarily  to 
the  flexion  of  the  forefoot  at  the  mediotarsal  joint,  and  in  many 
instances  this  dropping  of  the  forefoot  is  in  great  degree  respon- 
sible for  the  equinus;in  fact,  the  os  calcis  is  rarely  plantar  flexed 
to  the  degree  commonly  found  in  the  ordinary  congenital  equinus. 


Fig.  535 


Acquired  talipes  equinus,  showing  the  limitiofjdorsal  flexion. 

The  cases  of  slight  equinus  combined  with  cavus  have  been 
described  already  under  the  title  of  the  contracted  foot  (page  716). 

Etiology. — Equinus  is  the  most  common  of  the  forms  of  talipes 
accjuired  in  later  life.  Anterior  poliomyelitis,  although  by  far  the 
most  common  cause,  is  by  no  means  as  important  in  the  etiology 
of  this  as  of  other  varieties  of  deformity.  The  nerve  supply  of  the 
anterior  muscles  of  the  foot  seems  to  be  particularly  susceptible, 
and  toe-drop,  from  neuritis  of  various  types,  is  not  uncommon. 

Equinus  may  be  a  result  of  disease  of  cerebral  origin,  or  even, 
in  rare  instances,  of  pseudohypertrophic  muscular  paralysis,  loco- 
motor ataxia,  and  the  like.  It  is  sometimes  induced  by  habitual 
p(;sture,  as  by  long  confinement  in  bed  for  the  treatment  of  fracture 
or  during  the  treatment  of  hip  disease  by  apparatus.     Or  the  con- 


DEFORMITIES  OF  THE  FOOT  817 

traction  may  be  an  effect  of  voluntary  posture,  as  when  the  patient 
habitually  walks  upon  the  toes  because  of  a  short  limb.  It  is 
a  very  common  sequel  of  neglected  disease  at  the  ankle-joint, 
and  it  may  be  a  result  of  direct  injur)\ 

The  changes  in  the  internal  structure  of  the  foot  are  similar  to 
those  that  follow  other  forms  of  deformity;  the  tissues  on  the 
long  side  are  lengthened  and  attenuated,  while  those  on  the  short 
side  become  contracted.  The  bones  themselves  are  but  little 
changed  in  gross  appearance,  but  the  articulating  surfaces  are  in 
abnormal  relation  to  one  another;  for  example,  onlv  the  posterior 
part  of  the  astragalus  may  be  contained  within  the  malleoli  in 
relation  to  the  tibia,  while  only  the  lower  part  of  its  anterior  sur- 
face articulates  with  the  navicular.  In  all  cases  of  ecjuinus  there 
is  a  strong  tendency  toward  varus  or  valgus.  This  is  especially 
noticeable  in  those  of  paralytic  origin. 

Symptoms. — The  effects  of  the  deformity  vaiy.  If  the  limb 
is  actually  shorter  than  its  fellow,  so  that  the  lengthening  caused 
by  the  extension  of  the  foot  is  no  more  than  a  sufficient  compen- 
sation, and  if  the  foot  is  firmly  fixed  in  the  deformed  position, 
there  is  but  little  disability  and  the  principal  discomfort  is  from 
corns  or  calluses  beneath  the  metatarsal  bones. 

If  the  limb  is  not  shorter,  the  additional  length  caused  by  the 
equinus  must  be  compensated  by  a  tilting  of  the  pelvis  and  lateral 
deviation  of  the  spine.  This  often  causes  discomfort  in  the  lumbar 
region.  The  gait  in  this  class  of  cases  is  always  awkward,  giving 
the  impression  as  of  stepping  over  an  obstacle. 

If  the  foot  is  not  fixed  in  the  attitude  of  equinus — that  is,  if  it 
hangs  downward  when  it  is  lifted — the  gait  is  \evy  awkward, 
because  of  the  insecurity  and  because  of  the  exaggerated  flexion 
at  the  knee  necessaiy  to  lift  the  pendent  foot. 

If  the  equinus  is  extreme  the  limb  is  usually  flexed  at  the  knee 
when  in  use.  If  the  equinus  is  -so  slight  that  the  foot  may  be  used 
in  the  plantigrade  position,  the  strain  resulting  from  the  limita- 
tion of  dorsal  flexion  is  felt  at  the  knee;  and  in  childhood  especially 
there  is  often  a  well-marked  tendency  to  overextension  or  recur- 
vation, caused  by  the  effort  to  place  the  heel  upon  the  ground. 

In  the  slight  degrees  of  equinus,  discomfort  about  the  calf  is 
experienced;  the  limitation  of  dorsal  flexion  causes  a  short- 
ened stride  and  awkward  gait,  while  an  unguarded  step  that 
throws  a  sudden  strain  upon  the  rigid  heel  cord  is  felt  as  a  shock 
and  strain  through  the  leg  and  body,  ^'ery  often  the  patient 
complains  of  pain  about  the  metatarsal  bones  (anterior  metatar- 

52 


818  ORTUOPEDIC  SUEGEEY 

salgia),  and  if  the  eqiiiniis  is  accompanied  by  a  slight  degree  of 
valgus,  as  is  not  uncommon,  symptoms  of  the  weak  foot  may  be 
present. 

The  prognosis  as  to  permanent  cure  depends,  of  course,  upon 
the  cause  of  the  deformity.  When  it  is  simply  the  result  of  pos- 
ture or  of  the  ordinary  form  of  neuritis  and  the  like,  permanent 
cure  may  be  expected.  In  many  of  the  cases  caused  by  anterior 
poliomyelitis  there  has  been  recoveiy,  complete  or  partial,  of  the 
original  injur}'  to  the  spinal  centres.  But  although  the  power  has 
been  regained,  it  cannot  be  exercised  because  the  foot  is  held  in 
the  distorted  position  by  the  contracted  tissues.  In  such  instances 
practical  cure  may  be  predicted  if,  after  the  overcorrection  of 
deformity,  sufficient  time  is  allowed  for  the  overstretched  and 
atrophied  muscles  to  regain  their  proper  length  and  volume. 

Treatment. — In  the  cases  of  fixed  equinus  with  a  shortened 
limb  in  which  the  patient  suffers  no  discomfort  a  shoe  should  be 
so  built  that  the  entire  sole  may  support  the  weight.  In  the  more 
extreme  cases  in  which  the  limb  is  short  and  the  foot  is  atrophied 
an  extension  shoe,  attached  after  the  manner  of  an  artificial  leg, 
may  be  worn  with  comfort  and  with  but  little  evidence  of  deformity. 

In  the  ordinary  cases,  whether  permanent  cure  is  expected  or 
not,  the  rule  holds  good  that  the  heel  should  bear  weight,  and 
that  the  range  of  dorsal  flexion  should  not  be  limited  when  the  calf 
muscle  retains  its  power.  If  the  paralysis  is  permanent  the  foot 
must  be  supported  after  the  deformity  has  been  corrected;  but 
even  in  this  class  the  gait  may  be  improved  and  the  discomfort 
may  be  relieved  by  removing  the  restrictions  to  normal  motion. 

The  slight  degrees  of  equinus  in  young  subjects  may  be  over- 
come by  simple  manipulation  or  by  retention  in  a  splint  or  in  a 
plaster  bandage.  If  the  foot  is  fixed  by  a  plaster  bandage  at  a 
right  angle  to  the  leg  it  will  be  found  after  a  few  weeks  that  the 
range  of  dorsal  flexion  has  been  increased  by  the  rest  and  by 
functional  use.  Manual  stretching  of  the  contracted  tissues  is  also 
of  service;  for  example,  the  patient  being  seated  extends  the  limb; 
the  surgeon  stands  in  front  of  him,  one  hand  holds  the  leg 
firmly  at  the  ankle,  and  the  other  grasps  the  foot,  which  is 
then  dorsiflexed  over  and  over  again  with  as  much  force  as  is 
consistent  with  the  comfort  to  the  patient. 

Certain  forms  of  apparatus,  for  example,  the  Shaffer  extension 
shoe,  may  be  employed  witli  advantage  in  cases  of  slight  deformity. 

Immediate  Correction  of  Deformity. — ^Attention  has  been  called 
to  the  cavus  as  an  important  element  in  ccjuinus,  and  whenever 


DEFORMITIES  OF  THE  FOOT 


819 


one  attempts  to  correct  the  equinus  deformity  the  exaggerated 
arch  should  first  be  reduced  to  its  normal  depth,  otherwise  the 
foot  will  appear  stunted  and  deformed. 

One  of  the  most  effective  procedures  is  forcible  reduction  by 
means  of  the  Thomas  wrench  (Fig.  518).  The  resistant  bands 
of  the  plantar  fascia  are  first  divided  subcutaneously,  the  wrench 
is  then  fixed  to  the  foot,  and  by  sudden  force  exerted  against 
the  resistant  tendo  Achillis  the  foot  is 'straightened, 'the  con- 
tracted tissues  being  ruptured  or  stretched  to  the  proper  degree. 


Fig.  536 


Fig.  537 


A  brace  with  a  "limited"  joint,  allowing 
slight  motion  at  the  ankle. 


A  Ijrace  to  prevent  foot-drop.     One 
upright  is  often  suflBcient. 


The  resistance  to  normal  dorsal  flexion  is  then  overcome  by 
manual  force,  or,  if  this  is  inefl'ective,  by  subcutaneous  division 
of  the  tendo  iVchillis,  and  the  foot  is  fixed  by  a  plaster-of-Paris 
bandage  in  an  attitude  of  dorsiflexion. 

As  the  patient  is  encouraged  to  walk  upon  the  foot  as  soon  as 
possible,  the  weight  of  the  body  forcing  the  relaxed  tissues  against 
the  plaster  sole,  reinforced,  if  necessaiy,  by  a  wooden  foot-plate 
completes  the  flattening  of  the  arch.  In  many  of  these  cases  the 
knee  has  been  overextended  by  use  in  the  deformed  attitude,  so 
that  the  habitual  flexion  necessaiy  to  bring  the  dorsiflexed  fcot 


820  ORTHOPEDIC  SURGERY. 

upon  the  ground  during  the  two  months  allowed  for  the  complete 
union  of  the  di"\'ided  tendon  is  of  benefit,  as  it  serves  to  correct 
this  secondary  weakness  and  deformity. 

The  To^^c  Effect  of  Iivimediate  Correction. — The  im- 
portance of  the  tonic  effect  of  immediate  relief  of  the  strain  of 
the  deformed  position  upon  the  weak  anterior  group  of  muscles, 
together  with  the  complete  relaxation  of  the  overstretched  tissues, 
during  the  long  rest  in  the  overcorrected  position  is  not  generally 
appreciated.  Whenever  the  weakened  muscles  after  paralysis 
show  by  tests,  electrical  or  otherwise,  that  they  have  recovered 
their  power  in  part,  overcorrection  of  the  deformity  should  be 
the  treatment  of  selection.  The  application  of  electricity  or  other 
form  of  stimulation  to  muscles  that  are  unable  to  exercise  their 
function  because  of  contraction  of  the  opposing  tissues  is  practically 
useless;  nor  is  any  other  form  of  artificial  stimulation  equal  to 
that  of  the  functional  use,  which  is  made  possible  by  the  removal 
of  the  deformity  and  by  the  employment  of  proper  support. 
Equinus,  more  often  than  any  other  deformity,  is  the  result  of 
slight  or  temporary  disability  of  the  anterior  group  of  muscles, 
and  not  infrequently  perfect  cure  seems  to  have  been  attained 
when  the  plaster  bandage  is  finally  removed,  usually  at  the  end  of 
two  months  or  more;  but  even  in  such  cases  the  application  of 
a  simple  support  to  hold  the  foot  at  a  right  angle  with  the  leg  for 
several  months  is  of  advantage.  The  after-treatment  by  massage, 
muscle-beating,  electricity,  and  the  like,  combined  with  method- 
ical passive  movements  to  the  limit  of  dorsal  flexion  to  guard 
against  recontraction  of  the  calf  muscle,  should  be  continued  for 
a  long  time  or  until  the  muscular  balance  has  been  regained. 

Support  is,  of  course,  necessary,  in  cases  of  hopeless  paralysis, 
to  hold  the  foot  at  a  right  angle  with  the  leg.  The  common  form 
is  a  simple  steel  sole-plate  of  sufficient  size  to  support  the  sole, 
and  the  toes,  also,  if  their  muscles  are  paralyzed,  attached  to  a 
light  upright,  provided  with  a  calf  band.  The  upright  is  usually 
applied  on  the  inner  side  of  the  leg,  where  it  is  least  noticeable. 
At  the  ankle  there  is  a  "stop  joint,"  which  allows  dorsiflexion 
but  prevents  the  toe-drop.  This,  when  properly  fitted,  can  be 
placed  inside  the  ordinaiy  shoe,  as  the  paralyzed  foot  is  usually 
somewhat  smaller  than  its  fellow  (Fig.  537).  If  the  toes  do  not 
need  support,  the  upright  can  be  attached  to  the  outside  of  the 
shoe  and  the  foot-plate  may  be  dispensed  with;  or,  the  upright 
may  be  concealed  by  introducing  it  inside  the  shoe  to  a  joint  sunk 
in  the  heel,  the  toe-drop  being  prevented  by  straps  passing  from 


DEFORMITIES  OF  THE  FOOT 


821 


the  front  of  the  upper  leather  of  the  shoe  to  the  calf  band  (Fig 
538). 

Arthrodesis. — In  this  class  of  cases  in  which  the  anterior  muscles 
are  paralyzed  the  operation  of  arthrodesis  for  the  purpose  of 
fixing  the  foot  at  a  right  angle  with  the  leg  is  of  value.  In  most 
instances  the  mediotarsal  as  well  as  the  ankle-joint  must  be 
operated  on.  Under  the  Esmarch  bandage  the  two  joints 
are  opened  by  an  incision  in  the  centre  of  the  foot,  beginning 


Fig.   538 


ff\ 


An  effective  and  inconspicuous  support  for  paralytic  toe-drop.  An  upright  of  light  tem- 
pered steel,  carefully  adjusted  to  the  inner  side  of  the  leg  and  ankle,  provided  with  a  light 
calf  band.  This  is  strengthened  by  a  posterior  support  attached  to  the  upright.  The  lower 
end  of  the  brace  is  arranged  as  a  caliper  and  is  fitted  to  the  metal  disk,  of  which  two  view.s 
are  shown.  A  depression  is  cut  in  the  heel  of  the  shoe  for  the  disk,  as  is  shown  in  the  dia- 
gram. Two  strong  elastic  tapes  are  sewed  to  the  leather  of  the  shoe.  These  are  attached 
to  the  studs  on  the  front  of  the  calf  band,  and  thus  the  toe-drop  is  prevented.  (See  Fig.  539.) 

about  one  inch  above  the  ankle-joint  and  extending  downward 
for  about  three  inches.  The  cartilaginous  surfaces  of  the  astrag- 
alus and  leg  bones  may  be  removed  easily  with  a  narrow-bladed 
knife  or  tliin,  sharp  chisel,  while  the  foot  is  held  in  plantar  flexion. 
At  the  mediotarsal  joint  a  thin,  wedge-shaped  section,  base  up- 
ward, including  the  astragalonavicular  and  calcaneocuboid  joints, 
may  be  removed  also  in  order  to  prevent  the  subsequent  sinking 
of  the  forefoot. 


822 


ORTHOPEDIC  SURGERY 


Fig.  539 


If  there  is  restriction  of  dorsal  flexion  the  foot  should  be  forced 
up  to  a  right  angle  T\ith  the  leg  against  the  resistance  of  the  tendo 

Acliillis,  thus  pressing  the 
denuded  surfaces  together. 
In  other  instances  silk  sutures 
may  be  passed  through  the 
periosteum  of  the  opposing 
bones.  The  wound  is  then 
closed  with  catgut  ligatures 
and  a  plaster-of-Paris  band- 
age is  applied  to  hold  the 
foot  at  a  right  angle  with 
the  leg.  Operations  of  this 
character  on  the  bones  are 
sometimes  followed  by  swell- 
ing. On  tliis  account  the 
bandage  should  be  applied 
over  a  thick  layer  of  elastic 
cotton  and  the  foot  should 
be  elevated.  As  soon  as  the 
discomfort  has  subsided  the 
patient  should  use  the  foot  in 
walking.  No  support  is  equal 
in  efficiency  to  the  plaster 
bandage.  This  should  be 
worn  for  several  months, 
when  it  may  be  replaced  by 
a  light  supporting  brace  of 
the  Judson  type  (Fig.  541).  .  Equinus  due  to  posture  or  to  disease, 
not  involving  paralysis,  may  be  cured  by  simple  correction  of  the 
deformity.  Resistant  deformity  following  fractures  at  the  ankle 
may  be  overcome  satisfactorily  by  astragalcctomy. 


The  same  appliance  (Fig.  491)  provided  with  a 
foot  plate  of  metal  or  of  wood  as  shown  in  the 
diagram.  This  modification  is  useful  if  the  par- 
alysis is  complete  or  if  the  foot  is  much  atrophied. 


Acquired  Talipes  Calcaneus. 

Acquired  talipes  calcaneus  is  much  less  common  than  equinus, 
and  it  is  practically  always  of  paralytic  origin  (anterior  polio- 
myelitis), although  cases  of  calcaneus  following  injury  or  disease 
or  distortion  of  the  limb  are  occasionally  seen. 

There  are  several  varieties  or  grades  of  the  deformity.  In  the 
early  stage,  and  especially  if  all  the  muscles  of  the  posterior  group 
have  been  paralyzed,  the  foot  assumes  an  attitude  of  slight  dorsi- 


DEFORMITIES  OF  THE  FOOT  823 

flexion,  and  the  range  of  plantar  flexion  is  gradually  lessened  by 
secondary  contractions.  This  variety  resembles  closely  the  con- 
genital form  (simple  calcaneus)  (Fig.  485).  In  the  ordinars'  and 
typical  form  of  calcaneus,  when  fully  developed,  the  patient 
walks,  as  the  name  implies,  on  an  elongated  heel.  The  arch  of 
the  foot  is  much  increased  in  depth,  and  the  forefoot  is  atrophied 
and  useless  (calcaneocavus)  (Fig.  542). 

Development  of  Deformity. — The  development  of  the  deformity 
is  somewhat  as  follows:  "When  the  tension  of  the  calf  muscle  is 
removed  the  os  calcis  gradually  assumes  an  attitude  of  extreme 
dorsiflexion.  It  stands  on  end,  so  that  its  posterior  surface 
becomes  inferior.  The  projection  of  the  heel  is  lessened  and 
often  it  lies  in  the  plane  of  the  atrophied  calf.  The  change  in  the 
position  of  the  os  calcis  increases  the  distance  from  the  malleoli 
to  the  ground;  thus  calcaneus,  though  in  less  degree  than  equinus, 
makes  the  limb  longer.  The  turning  of  the  heel  on  end  increases 
the  depth  of  the  longitudinal  arch  and  at  the  same  time  shortens 
the  foot,  thus  cavus  is  a  later  complication  of  nearly  all 
cases  of  paralytic  calcaneus.  In  many  instances  there  is  no  per- 
manent dorsiflexion  or  elevation  of  the  forefoot,  although  in 
all  cases  the  range  of  plantar  flexion  is  limited.  In  this  class  the 
power  in  the  remaining  muscles  of  the  posterior  group  is  probably 
sufflcient  to  counterbalance  the  action  of  the  dorsiflexors.  Ca"vus 
is  thus  a  direct  efi^ect  of  the  displacement  of  the  os  calcis.  If 
the  entire  posterior  group  of  muscles  is  paralyzed,  while  the 
anterior  muscles  are  unafl^ected,  the  foot  will  be  somewhat  dorsi- 
flexed  and  the  cavus  will  be  less  marked.  If  the  calf  muscle  only 
(gastrocnemius  and  soleus)  is  paralyzed,  the  remaining  muscles 
of  the  posterior  group  will  counterbalance  the  dorsiflexors  and  at 
the  same  time  increase  the  cavus.  In  some  instances  the  calf 
muscle  alone  is  affected;  in  others  one  or  more  of  the  smaller 
muscles  may  be  paralyzed  also,  in  which  case  the  foot  is  usually 
turned  toward  varus  or  valgus.  The  changes  primarily  caused 
by  the  paralysis  and  by  unopposed  muscular  action  become  fixed 
by  habitual  use  and  by  secondaiy  adaptation  of  the  tissues.  The 
heel  only  is  used  in  walking,  and  the  area  of  callus  which  marks 
its  weio-ht-bearino;  surface  becomes  much  enlarged,  while  the 
forefoot  and  toes  become  a  mere  appendage  to  the  enlarged  heel, 
a  striking  illustration  of  the  atrophy  that  follows  disuse  (Fig.  542). 

Symptoms. — The  gait  is  shambling,  the  patient,  who  is,  as  it 
were,  "hamstrung,"  stamps  along  upon  the  insecure  heel  in  a 
manner  wliich  is   easily    recognizable  by   one    familiar  with  the 


824 


ORTHOPEDIC  SUBGERY 


deformity.  The  changes  in  the  internal  structure  of  the  foot,  the 
inevitable  adaptations  to  the  deformity,  do  not  call  for  special 
description.  The  disused  bones  atrophy  together  with  the  other 
tissues,  and  new  articulating  surfaces  form  to  accommodate  the 
necessities  of  functional  use. 

Treatment. — When  the  diagnosis  of  paralysis  of  the  calf  muscle 
is  made  one  may  predict,  unless  recovery  takes  place,  a  deformity 
such  as  has  been  described.  This  deformity  may  be  prevented  by 
proper  support,  by  massage  and  methodical  stretcliing  of  the  tissues 
that  have  a  tendency  to  contract.  The  form  of  brace  used  for 
walking  and  support  should  be  provided  with  a  sole  plate,  upright, 
and  calf  band,  as  already  described  in  the  treatment  of  paralytic 


Fig.  540 


Fig.  541 


Judson's  brace  for  calcaneus  deformity. 


equinus.  If  motion  is  allowed  at  the  ankle  it  should  be  in  plantar 
flexion  only,  the  stop  being  the  reverse  of  that  used  in  equinus; 
or,  as  this  form  of  check  entails  much  strain  upon  the  brace,  the 
joint  may  be  omitted,  as  in  that  form  used  by  Judson  (Figs.  540 
and  541  j.  Thus  the  strain,  removefl  from  the  weakened  tissues, 
is  Ijorne  by  the  anterior  surface  of  the  leg.  Other  forms  of 
braces  are  sometimes  employed,  provided  with  elastic  bands  to 
supply  the  place  of  the  calf  muscle;  but,  as  a  rule,  the  improve- 
ment in  gait  hardly  compensates  foi-  the  trouble  in  adjustment  or 
the  conspicuousness  of  the  appliance. 

The  most  important  part  of  the  actual  deformity  of  calcaneus 
is    the  cavus,  and    in    confirmed   cases  it    is    practically    impos- 


DEFORMITIES  OF  THE  FOOT 


825 


sible  to  reiliice  this  directly,  because  the  loss  of  resistance  of  the 
tendo  Achillis  takes  away  the  point  of  fixation  against  wliich 
effective  force  can  be  exerted.  If  the  deformity  is  not  marked 
the  foot  may  be  drawn  as  far  as  possible  toward  equinus  and 
fixed  in  a  plaster  bandage,  the  sole  part  being  strengthened  by 
the  insertion  of  a  thin  board.  Upon  this  the  patient  may  walk, 
the  heel  being  built  up  with  cork  wedges  to  make  the  sole  level. 
When  the  contraction  of  the  anterior  tissues  has  been  overcome 


Fig.   542 


Paralytic  calcaneus,  showing  secondary  changes  in  contour. 

the  brace  is  applied  and  the  usual  treatment  of  manipulation  and 
massage  is  continued. 

The  method  of  prolonged  fixation  in  the  attitude  of  equinus  by 
means  of  the  plaster  bandage  is  often  of  value  in  childhood, 
when  the  paralysis  is  not  complete,  and  cures  of  apparently  hope- 
less cases  by  this  means  have  been  reported.^ 

Operative  Treatment. — In  more  extreme  cases  inunediate  reduc- 
tion of  the  deformity  under  anaesthesia  may  be  attempted.  The 
contracted  tissues,  more  particularly  the  plantar  fascia,  may  be 

'  Gibney,  Transactions  of  the  American  Orthopedic  .Association,  1900,  vol.  xiii. 


826 


OB THOPEDIC  SURGERY 


dinded  subciitaneously  or  bv  open  incision;  then  bv  forcible 
manipulation  or  ^Yrenclling  the  sole  may  be  someAvhat  lengthened 
and  the  heel  pushed  upward  and  backward  to  permit  of  slight 
plantar  flexion.  In  tliis  attitude  the  foot  should  be  fixed  by 
means  of  a  plaster  bandage.  In  the  reduction  of  the  deformity 
one  must  not  merely  force  the  forefoot  downward,  as  tliis  would 
simply  increase  the  cavus,  but  whatever  correction  is  accomplished 
should  be  bv  means  of  elevation  of  the  os  calcis  and  elongation 


Fig.   543 


Talipes  calcaneus  due  to  paralysis  of  the  calf  muscle  (gastrocnemius  and  soleus), 
illustrating  the  typical  deformity  of  moderate  degree. 


of  the  tissues  of  the  sole  of  the  foot.  In  cases  of  extreme  de- 
formity the  contracted  tissues  in  the  anterior  aspect  of  the  ankle 
must  be  divided  also. 

In  some  instances  the  improved  position  of  the  os  calcis  may 
be  assured  by  shortening  the  tendo  Achillis,  as  first  performed 
by  Willett,  of  London.^ 

Willett's  Operation  for  Calcaneus. — A  Y-shaped  incision  about 
two  inches  in  length  is  made  through  the  tissues  down  to  the 
tendon.  At  the  lower  or  vertical  part  of  the  incision,  which  is 
continued  down  to  the  tuberosity  of  the  os  calcis,  the  tendon  is 

'   St.  Bartholo  ui'.w's  llosjjital  Reports,  tSSO,  vol.  xvi,  |).  HOU. 


DEFORMITIES  OF  THE  FOOT 


827 


dissected  free  from  the  surrounding  parts.     It  is  then  dividecJ  in 
an  oblique  direction  from  within  outward  and  downward,  and  the 


Fig.   544 


Talipes  calcaneovalgus.     In  this  form  the  adductors  of  the  foot  (tibialis  anticus  ami 
posticus)  as  well  as  the  calf  muscle  are  paralyzed. 

heel  having  been  pushed  upward  as  far  as  possible  the  divided  ends 
are  overlapped  and  sutured;  the  flap  of  skin  is  drawn  downward 


Fig.  545 


Fig.  546 


Illusi  r.iiinu;  ihe  elVeci  of  the  operation  in  restoring  symmetry. 
Compare  with  Fig.  543.  Compare  with  Fig.  544. 

at  the  same  time,  so  that  the  Y-incision  is  converted  into  the 
shape  of  a  V.  According  to  INIr.  "Willett's  original  directions, 
deep  sutures  are  passed  through  the  skin  flaps  and  through  the 


828 


ORTHOPEDIC  SURGERY 


tendon  on  either  side,  so  that  all  the  tissues  are  united.  The 
foot  is  then  fixed  in  a  plaster  bandage  in  an  attitude  of  equinus. 
As  soon  as  practicable  the  patient  begins  to  use  the  foot,  wearing 
a  high  heel  to  compensate  for  the  elevation  of  the  sole. 

Palliative  operations  of  this  class  are  of  value  in  those  cases  in 
which  some  power  remains  in  the  calf  muscle,  wliich  is  thus 
made  ser\'iceable.  In  cases  of  complete  paralysis  the  shortened 
tendon  offers  some  resistance  to  deformity,  but  unless  proper 
support  is  used  afterward  the  tissues  will  stretch  under  the  strain 
of  use;  thus  the  treatment  should  always  be  supplemented  by  a 
brace  of  the  character  already  described  (Fig.  541). 

Fig.   547 


Figs.  544,  545,  and  546  illustrate  the  effect  of  treatment  by  removal  of  the  astragalus  and 
backward  displacement  of  the  foot  in  cases  of  paralytic  talipes  calcaneovalgus.  In  the 
later  operations  the  backward  displacement  has  been  increased  as  described  in  the  text. 

Astragalectomy,  Arthrodesis,  Tendon  Transplantation,  and  Backward 
Displacement  of  the  Foot  (the  Author's  Operation^). — More  effective 
treatment  is  indicated  in  cases  of  confirmed  calcaneus  and  especially 
calcaneus  combined  with  lateral  deformity  which  makes  the  adjust- 
ment of  a  Vjrace  difficult. 

A  long,  curved,  external  incision  is  made,  passing  from  a  point 
behind  and  above  the  external  malleolus  below  its  extremity  and 
terminating  at  the  outer  aspect  of  the  head  of  the  astragalus. 
The  peronei  tendons  are  divided  as  far  forward  as  possible  and 
they  are  then  completely  separated  from  their  sheaths  and  drawn 
to  one  side.    The  joint  is  then  opened  and  the  foot  is   displaced 


'   American  Journal  of  the  .Medical  Sciences,  November,  1901. 


DEFORMITIES  OF  THE  FOOT 


829 


inward.  This  forces  the  astragalus  out  from  between  the  malleoli 
and  it  is  easily  enucleated  when  its  attachments  to  the  neighboring 
bones  have  been  divided.  A  thin  section  of  bone  is  then  cut  from 
the  outer  surface  of  the  os  calcis  and  cuboid  bones.  On  the  inner 
side  the  sustentaculum  tali  is  cut  away  and  the  calcaneona\acular 
ligament  is  partially  separated  from  its  attachments.  The  carti- 
lage is  then  removed  from  the  two  malleoli  and  if  necessary  they 
are  reshaped  to  permit  accurate  adjustment.  The  foot  is  then 
displaced  backward  as  far  as  possible  so  that  the  external  malleolus 
may  cover  the  calcaneocuboid  junction  while  the  inner  is  forced 

Fig.  548 


An  effective  brace  for  talipes  calcaneus,  consisting  of  two  light  lateral  steel  bars  joined 
above  by  a  padded  band  of  steel,  which  crosses  the  upper  third  of  the  tibia,  and  below  by  a 
narrow  sole  plate.  A  leather  heel  support  also  adds  somewhat  to  the  efficiency  of  the  appa- 
ratus. In  most  instances  the  heel  should  be  somewhat  elevated  by  a  cork  wedge  placed 
within  the  shoe. 

into  the  depression  behind  the  navicular.  Finally,  the  peronei 
tendons,  if  the  muscles  are  active,  are  attached  to  the  insertion  of 
the  tendo  Achillis  and  to  the  os  calcis  by  strong  silk  sutures.  The 
wound  is  closed  without  drainage,  and  the  foot  is  then  fixed  by  a 
plaster  bandage  in  an  attitude  of  equinus.  The  object  of  the 
removal  of  the  astragalus  is  to  assure  stability  and  to  prevent 
lateral  ceformity  by  placing  the  leg  bones  directly  upon  the 
foot.  The  object  of  the  l>ackwai-tl  displacement  of  the  foot 
is  to  direct  the  weiglit  upon  its  centre  and  thus  to  remove  the 
adverse  leverage  that  induces  dorsal  flexion.  The  tendon  trans- 
plantation is  an  additional  safeguard  against  deformity  and  of 
some  service  in  restorine;  function. 


830  ORTHOPEDIC  SURGERY 

As  soon  as  possible  the  patient  uses  the  foot  in  standing  and 
walking.  Ultimately  apparatus  mav  be  dispensed  with,  but  the 
Judson  brace  or  the  appliance  shown  in  Fig.  54S  should  be  used 
for  a  year  or  more  with  advantage,  when  it  may  be  replaced  by 
a  shoe  arranged  to  hold  the  foot  in  slight  equinus.  This  operation 
has  been  performed  in  upwards  of  fifty  cases  h\  the  author,  for 
whom  it  is  now  the  treatment  of  choice  in  this  type  of  deformity. 

Acquired  Calcaneovalgus  and  Calcaneovarus. 

In  many  cases,  the  foot  deformed  as  a  result  of  paralysis  of 
the  calf  muscle  is  in  addition  turned  in  a  lateral  direction,  so 
that  the  weight  of  the  body  falls  to  the  inner  or  outer  side  of  its 
centre  (Fig.  544). 

Calcaneovalgus,  in  which  the  foot  is  turned  outward  and 
upward,  so  that  the  patient  walks  on  the  inner  side  of  the  heel  or 
even  on  the  inner  ankle,  is  not  uncommon.  It  is  usually  a  result 
of  more  extensive  paralysis  than  simple  calcaneus.  For  example, 
all  the  muscles  about  the  foot  may  be  disabled  except  the  peronei, 
or  in  cases  of  a  milder  type  the  tibialis  anticus  may  be  the  only 
muscle  of  the  front  of  the  foot  that  is  paralyzed. 

Treatment.— When  the  foot  inclines  toward  calcaneovalgus  it 
is  difficult  to  hold  it  in  proper  position.  The  usual  method  is  to 
apply  the  brace,  used  for  ordinary  calcaneus,  with  the  upright  on 
the  outer  side  of  the  foot;  the  ankle  and  arch  are  then  held  against 
it  by  means  of  a  leather  strap.  Another  form  of  brace  is  provided 
with  an  upright  on  either  side  of  the  leg,  the  outer  being  slightly 
longer  than  the  inner,  so  that  the  sole  plate  is  tilted  inward  or, 
as  it  were,  supinated;  thus  the  weight  is  guided  toward  and  bal- 
anced on  the  outer  side  of  the  foot.  In  many  instances  of  this 
character  other  muscles  of  the  limb  are  paralyzed,  the  deformity 
of  the  foot  being  but  a  part  of  more  general  distortion.  In  such 
cases  the  foot  brace  must  be  combined  with  apparatus  for  the 
support  of  the  leg  (Fig.  394). 

Calcaneovarus  is  a  much  less  serious  affection,  since  the  foot 
may  be  more  easily  supported.  A  brace,  such  as  is  used  in  the 
treatment  of  ordinary  varus,  without  motion  at  the  ankle  or 
provided  with  a  reverse  stop,  is  ordinarily  emploj/ed.  Operative 
treatment  is  especially  indicated  for  confirmed  deformity  of  the 
valgus  or  varus  type  after  the  method  last  described. 


DEFORMITIES  OF  THE  FOOT  831 


Acquired  Talipes  Equinovanis. 

Talipes  equinovanis  is,  in  the  acquired  as  in  the  congenital 
form,  the  most  common  of  the  deformities  of  the  foot  (Fig.  552). 

The  tendency  of  simple  equinus  is  usually  toward  varus,  because 
in  plantar  flexion  the  foot  is  slightly  adducted  and  because  the 
outer  side  of  the  foot  is  shorter  than  the  inner  side,  so  that  in 
walking  with  the  foot  extended  the  tendency  of  the  foot  is  to 
turn  somewhat  inward.  Equinovarus  is  usually  preceded  by 
equinus,  and  the  etiology  of  the  one  will  serA'e  for  the  other  (page 
815). 

In  certain  cases  the  varus  is  more  marked  than  the  equinus, 
as,  for  example,  when  the  abductors  of  the  foot  are  paralyzed 
while  the  adductors  retain  their  power;  or  in  cases  of  direct  injur}-, 
as  in  fracture  at  the  ankle;  or  when  the  growth  of  the  tibia  has 
been  arrested,  as  the  result  of  injury  or  disease. 

A  detailed  account  of  the  appearance  and  effect  of  the  deformity 
is  unnecessary. 

If  the  deformity  is  resistant  it  should  be  reduced  and  overcor- 
rected  by  forcible  manipulation  under  anaesthesia.  Division  of  re- 
sistant parts  is  less  often  necessary  than  in  the  congenital  form,  but 
it  may  be  required  in  neglected  cases.  The  overcorrected  position 
should  be  retained  until  time  has  been  allowed  for  the  recontrac- 
tion  of  the  lengthened  tissues;  for,  as  has  been  mentioned  in  the 
treatment  of  equinus,  overcorrection  and  rest  is  by  far  the  most 
effective  treatment  that  can  be  applied  to  a  weak  or  paralyzed 
part.  The  foot  must  then  be  supported  by  a  brace,  of  wliich  the 
Taylor  club-foot  apparatus  is  the  type  (Fig.  505). 

Astragalectomy  and  cuneiform  osteotomy  are  rarely  indicated, 
but  the  latter  operation  is  sometimes  of  service  in  checking  the 
tendency  toward  recurrence  of  deformity,  which  is  more  persistent 
jifter  overcorrection  in  the  paralytic  than  in  the  congenital  talij^es. 

Transplantation  of  half  of  the  tendon  of  the  tibialis  anticus 
tendon  to  the  periosteum  or  bone  of  the  outer  border  of  the  foot, 
combined  Avith  arthrodesis  of  the  astrao-ahis  navicular  articulation 
in  an  attitude  of  slight  abduction,  is  of  service  as  a  curati\e  pro- 
cedure.    (See  Tendon  Transplantation.) 

Acquired  Talipes  Equinovalgus  is  much  less  frequent  than  the 
preceding  deformity.  Simple  equinovalgus  is  usiudly  the  result 
of  primaiT  paralysis  of  the  tibialis  anticus,  the  most  powerful  of 
the   dorsal    flexors;   thus   the  foot   is   drawn   somewhat   outward 


832  ORTHOPEDIC  SURGERY 

when  dorsiflexed,  wliile  the  metatarsal  bone  of  the  great  toe, 
having  lost  the  proper  support  of  the  paralyzed  muscle,  falls  down- 
ward and  is  drawn  outward  by  the  peroneus  longus.  In  tliis 
type  one's  attention  is  often  attracted  by  the  peculiar  appearance 
of  the  great  toe,  which  is  deformed  somewhat  like  a  hammer-toe 
by  the.  overaction  of  the  extensor  longus  hallucis  in  its  attempt 
to  take  the  place  of  the  tibialis  anticus.  The  equinus  is  usually 
slight  and  is  secondary'  to  the  valgus.  Treatment  may  be  begun 
by  placing  the  foot  in  a  plaster  bandage  in  an  attitude  of  varus 
and  allowing  the  patient  to  walk  upon  it  until  the  tendency 
toward  deformity  has  been  overcome.  A  support  with  the  catch, 
as  for  toe-drop,  is  applied  to  the  shoe,  and  the  tendency  toward 
valgus  is  checked  by  raising  the  inner  border  of  the  sole  or  by  the 
use  of  a  sole  plate,  as  in  the  treatment  of  the  simple  weak  foot 
(Fig.  455).  In  this  class  of  cases  tendon  transplantation,  partic- 
ularly the  implantation  of  the  tendon  of  the  extensor  longus 
hallucis  in  the  region  of  the  navicular,  combined  with  arthrodesis 
of  the  astragalona^-icular  articulation  to  fix  the  foot  in  the 
attitude  of  adduction  is  particularly  effective. 

Acquired  Simple  Talipes  Valgus  from  combined  paralysis  of 
the  tibialis  anticus  and  posticus  is  rare.  Talipes  valgus,  as  when 
the  foot  is  dislocated  outward,  in  cases  of  complete  paralysis  of 
all  its  muscles,  may  be  considered  as  a  variety  of  dangle-foot. 

Traumatic  valgus  and  equinovalgus  caused  by  fracture  at  the 
ankle  (Pott's  fracture)  may  be  treated  by  osteotomy  of  the  tibia 
above  the  ankle.  By  this  means  the  proper  relation  of  the  leg 
to  the  foot  may  be  restored  in  many  instances.  Equinovalgus 
of  slight  degree  is  not  uncommon  after  tuberculosis  or  rheumatoid 
disease  at  the  ankle  or  at  the  astragalonavicular  joints.  This  is 
practically  one  variety  of  weak  foot. 

Talipes  valgus,  sometimes  called  spurious  valgus,  the  simple 
weak  or  flat-foot,  has  been  described  elsewhere.     (Chapter  XX.) 

Talipes  caused  by  cerebral  disease,  whether  of  the  paraplegic 
or  the  hemiplegic  type,  is  in  early  childhood  almost  always  of 
the  form  of  equinovarus.  In  adolescence  the  deformity  may  be 
equinovalgus  or  even  calcaneo valgus  if  there  is  extreme  flexion  at 
the  knee.  The  heinij)legic  form  of  talipes  is  much  more  rigid 
and  unyielding  than  the  paraplegic  type.  The  treatment  of 
spastic  paralysis,  of  which  the  deformity  is  a  part,  is  discussed 
elsewhere.  (Chapter  XVIII.)  The  deformity  must  be  corrected 
by  the  ordinary  methods.  In  many  instances  when  the  contrac- 
tions are  not  marked  niefhaiiicul  treatment  is  unnecessary. 


DEFORMITIES  OF  THE  FOOT  833 

Hysterical  equinovarus  or  other  form  of  deformity  is  not  espe- 
cially rare.  The  diagnosis  may  be  made  from  the  other  symptoms 
of  hysteria,  from  the  histoiy  of  the  onset  and  duration  of  the 
distortion,  and  from  the  appearance  of  the  deformity,  which  is 
evidently  merely  an  assumed  posture.     (See  page  638.) 

Tendon  Transplantation  for  the  Relief  of  Paralytic  Talipes. 

When  one  or  more  of  the  muscles  are  paralyzed  the  unbalanced 
action  of  those  that  remain  tends  to  distort  the  foot.  The  object 
of  the  brace  in  such  cases  is  to  hold  the  foot  so  that  the  muscular 
traction,  however  applied,  can  move  it  only  in  the  proper  direc- 
tions. The  object  of  tendon  or  muscle  transplantation  is  to  utilize 
the  muscular  power  that  remains  to  the  best  advantage.  Thus  a 
muscle  which  only  serves  to  distort  the  foot  may  be  transplanted 
to  a  point  where  it  may  restrain  deformity  and  improve  functional 
ability. 

Tendon  transplantation  was  first  performed  by  Nicoladoni  in 
1882^  for  the  relief  of  paralytic  calcaneus.  The  tendons  of  the 
peroneus  longus  and  brevis  were  divided  behind  the  external 
malleolus,  and  the  proximal  ends  united  to  the  distal  extremity 
of  the  divided  tendo  Achillis. 

The  first  operation  on  the  front  of  the  foot  was  performed 
by  Parish,^  of  New  York,  for  the  relief  of  paralytic  valgus,  by 
sewing  the  tendon  of  the  extensor  proprius  hallucis  to  that  of  the 
paralyzed  tibialis  anticus,  without  division  of  either  tendon.  In 
more  recent  years  the  field  of  the  operation  has  been  extended  by 
Drobnik,^  Goldthwait,^  Lange,  and  many  others,  to  include  almost 
eveiy  possible  combination  of  tendons  and  muscles.' 

The  functions  of  the  muscles  and  their  relative  order  of  impor- 
tance in  the  execution  of  each  movement  are  indicated  in  the 
following  table,  modified  somewhat  from  that  of  Codivilla: 

1  Archiv  f.  klin.  Chir.,  1S82,  iii.,  xxvii.,  S.  660. 

2  New  York  Medical  Journal.  October  8,  1892. 

3  Cent.  f.  Chir.,  July,  1894,  N.  7. 

■*  Transactions  of  the  American  Orthopedic  Association,  1896,  vol.  viii. 
'■'  For  a  complete  bibliography  up  to  1902,  see  Yulpius,  Die  Sehneuiiberpflanzung,  etc., 
Leipzig,  1902. 


53 


834  0^  TH  OPE  Die  SVEOER  Y 


Dorsal 

Plantar 

Adduc- 

Abduc- 

Prona- 

Supina - 

flexion. 

flexion 

tion. 

tion. 

tion. 

tlon. 

Tibialis  anticus 

1 

... 

1 

Extensor  proprius  hallucis.     . 

o 

".!'. 

6 

longus  digitoruiu'    . 

2 

... 

3 

3 

Peroneus  brevis 

(> 

2 

2 

longus 

S 

1 

i 

Gastroonemilis  and  soleus 

1 

2 

2 

Tibialis  postioiis         .... 

4 

1 

3 

Flexor  longus  ballucis 

•1 

3 

4 

"          "      digitorum  . 

5 

4 

... 

5 

Time  for  Operation. — The  operation  should  not  be  undertaken 
until  the  degree  of  final  and  irremediable  paralysis  has  been 
determined.  This  stationars'  stage  may  be  reached  in  a  com- 
paratively^ short  time,  but  in  the  ordinary  cases  in  which,  for 
want  of  protection,  the  part  has  become  distorted,  it  is  practically 
impossible  to  estimate  the  latent  muscular  power  until  the  defor- 
mity has  been  corrected,  and  until  the  enfeebled  muscles  have 
been  stimulated  by  functional  use.  In  general,  a  period  of  two 
years  at  least  should  intervene  between  the  onset  of  the  paralysis 
and  the  operation. 

The  first  essential  for  success  by  this  means  is  a  clear  under- 
standing of  the  mechanism  of  the  disabled  part  and  of  the  relative 
importance  of  its  functions.  As  regards  the  foot,  for  example, 
plantar  flexion  is  far  more  important  than  dorsal  flexion,  because 
the  inability  to  plantar  flex  implies  the  loss  of  the  principal  lifting 
and  propelling  power  of  the  body.  Dorsal  flexion  is  more  im- 
portant than  adduction  or  abduction,  because  the  drop-foot, 
so-called,  interferes  seriously  with  locomotion.  Adduction  is 
more  important  than  abduction,  because  the  loss  of  power  to 
turn  the  foot  inward  induces  the  attitude  of  valgus,  which  is  more 
disabling  and  more  difficult  to  remedy  than  the  opposite  deformity. 
To  the  importance  of  these  movements  the  power  of  the  muscles 
corresponds.^ 

Selection  of  Muscles. — In  selecting  muscles  for  transplantation 
one  attempts  usually  to  reduce  the  distorting  power  as  well  as 
to  replace  lost  function.  For  example,  if  the  tibialis  anticus 
were  paralyzed  one  would  naturally  replace  it  by  its  adjunct, 
the  extensor  hallucis,  and  as  the  power  of  raising  the  toe  is  not 
essential  it  should  be  separated  and  transferred  entire  to  its  new 
position.  This  might  complete  the  operation,  or  the  principal 
abductor  on  the  dorsal  surt'ace  of  the  foot  might  be  divided  and 

'   Including  peroneus  tertius. 
2  See  Tables  on  page  07G. 


Fig.   549 


Fig.  550 


f  F//^^  'Wk 


f    ^ 


^  '  ^ai 


\>^ //(y        'til 


.iT^ 


The  muscles  aiul  teiuloiis  on  the  front  of  the     The  m  .  tendons  on  the  back  of  the 

leg  (Testut,  from  Gerrish's  Anatomy.)  leg.     i,  lestut,  from  Gerrish's  Anatomy.) 


836 


ORTHOPEDIC  SUROERY 


Fig.  551 


the  proximal  end  attached  to  the  periosteum  or  bone  near  the  centre 
of  the  foot  to  further  assure  the  success  of  the  operation. 

If,  on  the  other  hand,  the  dorsal  abductors  were  reduced  in 
strength  so  that  the  foot  turned  inward  in  dorsiflexion,  the  tibia- 
lis anticus  tendon  should  be  split,  from  its  insertion  to  the  mus- 
cular substance,  and  the  outer  half 
carried  over  the  other  tendons  and 
fastened  securely  at  or  near  the  in- 
sertion of  the  peroneus  tertius  as  well 
as  to  that  tendon;  thus  the  power  of 
supination  would  be  weakened  and 
that  of  pronation  increased. 

If  the  calf  muscle  is  paralyzed,  and 
if  the  foot  is  inclined  toward  valgus 
because  of  weakness  of  the  adductor 
group,  the  two  peronei  tendons  may 
be  attached  at  the  insertion  of  the  tendo 
Achillis,  not,  of  course,  with  the  aim  of 
replacing  its  lost  function  by  two  such 
feeble  muscles,  but  because  they  might 
aid  in  preventing  deformity  and  be- 
come of  some  functional  service,  even 
if  slight. 

Paralysis  of  the  tibialis  posticus 
muscle  may  be  treated  by  dividing  the 
peroneus  brevis  at  or  near  its  inser- 
tion, passing  it  beneath  the  tendo 
Achillis  and  attaching  it  to  the  tendon 
of  the  former.  It  may  be  mentioned, 
also,  that  portions  of  the  tendo  Achillis 
have  been  used  to  strengthen  either  the 
posterior  adductors  and  abductors.  As 
has  been  stated,  one  must  plan  the  oper- 
ation accordine;  to  the  function  that  is 
lost  and  the  power  that  remains.  As 
a  rule,  the  most  successful  operations 
are  those  in  which  a  muscle  of  similar  function  to  that  of  the 
paralyzed  one  is  transplanted.  It  is  apparent,  also,  that  it  will  be  of 
little  use  to  transpose  a  muscle  unless  its  origin  is  such  that  it  can 
work  to  advantage  at  its  new  point  of  attachment.  For  example, 
an  anterior  adductor  may  be  changed  to  an  abductor,  and  a 
{wsterior  adductor  or  abductor  can  be  similarly  transferred,  but  a 


Tendons  in  the  right  sole.     (Testut 
from  Gerrish'a  Anatomy.) 


DEFORMITIES  OF  THE  FOOT 


837 


posterior  abductor  is  unlikel\  to  be  efficient  as  a  dorsal  flexor; 
nor  can  one  muscle  act  as  an  extensor  and  as  a  flexor  at  the  same 
time,  as  would  appear  to  be  the  belief  of  those  who  attach  a  portion 
of  the  tendo  Achillis  to  the  tibialis  anticus  tendon  with  the  aim 
of  restoring  the  power  of  dorsal  flexion.  The  variety  of  com- 
binations of  this  character  that  have  been  advocated  is  verv  large, 
but  it  is  hardly  necessary  to  describe  them.  As  has  been  men- 
tioned, one  may  always  sacrifice  a  less  important  to  a  more  im- 
portant function,  and  as  a  weak  muscle  can  hardly  cany  out  its 


Fig.   552 


Paralj'tic  equinovarus  before  operation.     (See  Fig.  553.) 

original  function  and  a  more  important  one  as  well  it  is  advisable 
in  most  instances  to  relieve  it  completely  of  the  first  in  making 
the  transfer. 

The  Operation. — The  technique  of  the  operation  is  simple.  All 
restriction  to  normal  motion  must  be  overcome  by  manual  force, 
and,  if  necessary,  by  tenotomy  as  a  preliminary  measure.  The 
operation  should  be  performed  under  an  Esmarch  bandage. 
The  incision  either  continuous  or  divided  shotdd  expose  the  mus- 
cular substance  of  the  muscles  and  the  point  at  which  the  tranS' 
planted  tendon  is  to  be  attached.     By  exposing  the  parts  one  is 


838 


OB  THOPEDIC  S  UB  GEB  Y 


able  to  verify  the  previous  diagnosis.  A  completely  paralyzed 
muscle  is  atrophied  and  of  a  dull,  reddish-yellow  color,  and  its 
tendon  is  of  a  yellowish-white  tinge.  A  partially  paralyzed  muscle 
is  atrophied,  its  tendon  is  small,  but  it  retains  the  silvery  glisten 
of  the  normal  structure.  The  tendon  sheaths  having  been  opened, 
the  tendon  is  divided  or  split  near  its  insertion,  and  having  been 
freed  from  any  restraint  that  might  impair  its  power  it  is  placed 
in  apposition  to  the  tendon  of  the  paralyzed  muscle,  whose  surface 
has  been  freshened  with  the  knife.  The  two  are  then  attached  to 
one  another  bv  several  sutures  of  fine  silk,  and  the  e^raft  is  covered 

Fig.   553 


Paralytic  eqmnovarus  cured  by  operation,  showing  power  of  dorsal  flexion  (one-half  of 
the'tendon  of  the  tibialis  anticus  attached  to  the  periosteum  of  the  outer  border  of  the  foot) . 
Operation  July  19,  1898.  The  direct  union  of  tendons  to  periosteum  at  the  most  advantage- 
ous point  has  been  urged  especially  by  Lange  (Ueber  Perio.stale  Schnenverplanzung  bei 
Lahgmung,  Miinch.  med.Woch.,  1900,  No.  15). 

by  uniting  the  tendon  sheath  or  fatty  tissue  over  it  with  fine  cat- 
gut. The  skin  incision  is  closed  with  a  continuous  catgut  suture. 
It  should  be  stated  that  the  graft  is  applied  under  a  certain  tension, 
all  the  slack  being  drawn  in,  as  it  were,  so  that  the  foot  is  held  if 
possible  in  the  normal  attitude.  This  is  further  assured  in  most 
instances  by  shortening  the  tendon  of  the  paralyzed  mu.scle.  A 
plaster  bandage  is  then  applied  in  the  overcorrected  position, 
and  in  this  attitude  the  foot  should  be  used  for  many  months. 

Modifications  of  the  Operation. — Since  its  introduction  the  opera- 
tion of  tendon  transplantation  has  been  modified  in  several  par- 
ticulars.    It  has  been  demonstrated  by  experience  that  there  is 


DEFORMITIES  OF  THE  FOOT 


839 


a  strong  tendency  toward  relapse  to  the  original  condition,  either 
because  of  weakness  of  the  transposed  muscle  or  because  of 
displacement  of  the  new  attachment.  This  indicates  the  neces- 
sity of  long  continued  fixation  in  the  overcorrected  attitude  and 
of  subsequent  support  by  braces  until  one  is  certain  of  the  final 
outcome. 

It  has  been  urged  by  Lange  that  the  tendon  of  the  living  muscle 
should  not  be  attached  to  that  of  the  paralyzed  one,  but  should 
be  fixed  directly  to  the  periosteum  at  the  point  of  greatest  mec-han- 


FiG.    554 


Talipes  equinovalgus  after  treatment  by  tendon  transplantation.  The  tendon  of  the 
peroneus  tertius  was  attached  to  the  overlapped  and  shortened  tendon  of  the  tibialis  anticus. 
A.11  the  tendons  on  the  front  of  the  foot  were  then  united,  so  that  all  might  serve  as  dorsal 

flexors. 


ical  efficiency.  If  the  tendon  is  not  long  enough  for  this 
purpose  it  may  be  lengthened  by  means  of  a  silk  cord  incorpoi- 
ated  in  its  substance,  about  which  it  is  assumed,  new  tendinous 
material  will  form  during  its  absorption.  Wolff  has  suggested 
implanting  the  end  of  the  tendon  beneath  the  cortex  of  the  bone, 
and  I  have  gone  still  farther  in  the  interest  of  security  by  boring 
a  hole  completely  through  the  bone  to  which  the  attachment  is  to 
be  made,  passing  the  tendon  through  it  and  sewing  it  to  itself 
and  to  the  periosteum  on  the  other  side.  Thus,  in  utilizing  the 
extensor  longus  hallucis  to  replace  the  tibialis  anticus  the  hole  is 


840  OBTHOPEDIC  SURGERY 

made  in  the  navicular.  The  tendon,  having  been  divided  about 
one  inch  from  its  insertion,  is  passed  through  and  drawn  tight 
enough  to  hold  the  inner  border  of  the  foot  at  a  right  angle  to 
the  leg.  The  tendon  of  the  paralvzed  tibialis  anticus  is  then  cut, 
overlapped,  and  sutured  to  aid  in  relieving  the  strain.  If  the 
tibialis,  anticus  muscle,  on  the  other  hand,  is  to  be  used  as  an 
abductor  it  is  split  in  the  manner  described,  and  as  it  is  not  long 
enough  for  bone  implantation  a  cord  of  silk  is  quilted  into  it  and 
passed  through  the  cuboid,  while  the  tendon  itself  is  attached  to 
that  of  the  peroneus  tertius  and  to  the  periosteum  in  the  usual 
manner.  Silk  may  be  depended  upon  to  hold  for  several  months, 
although  it  is  not  completely  absorbed  for  several  years.  For 
uniting  adjacent  tendons  the  continuous  suture  over  a  wide  extent 
of  surface  is  most  secure. 

Tendon  Transplantation  in  Combination  v^ith  Other  Procedures. — 
As  the  object  of  operative  treatment  is  to  prevent  deformity  and 
to  increase  the  stability  of  the  foot,  tendon  transplantation  may 
be  of  greater  service  when  combined  with  other  operations.  One 
of  these  has  been  mentioned  in  the  treatment  of  talipes  cal- 
caneus. (See  page  828.)  For  valgus  deformity  arthrodesis  of  the 
astragalonavicular  articulation  is  a  valuable  adjunct  of  tendon 
transplantation.  An  incision  about  three  inches  in  length,  long 
enough  to  expose  the  muscular  substance  of  the  extensor  longus 
hallucis  and  the  astragalonavicular  articulation  is  made.  This 
joint  is  then  opened  and  the  cartilage  is  thoroughly  removed  from 
the  adjoining  bones.  A  hole  is  then  bDred  through  the  navicular 
through  which  the  hallucis  tendon  is  passed.  This  is  drawn 
taut  and  sewed  to  the  bone  and  to  itself.  The  foot  is  forced 
into  an  attitude  of  adduction  and  the  denuded  bones  are  sewed 
firmly  to  one  another  with  strong  silk.  A  similar  procedure  is 
employed  if  the  deformity  is  of  the  varus  type.  A  thin  wedge  of 
})one,  including  the  calcaneocuboid  and  the  outer  half  of  the 
astragalonavicular  articulation,  is  removed  from  the  dorsal  aspect 
of  the  foot.  Forced  abckiction  closes  the  opening  and  continued 
contact  is  assured  by  several  heav}/  silk  sutures. 

The  foot  should  be  retained  for  several  months  in  the  over- 
corrected  position  by  a  plaster  bandage,  on  which  the  patient 
walks  a})Out  until  the  parts  have  become  adapted  to  the  new  posi- 
tion. In  many  instances  further  support  is  unnecessary,  but  a 
l>race  should  be  used  if  there  is  a  tendency  toward  deformity. 

The  prognosis  depends  upon  the  degree  of  permanent  paralysis 
and  its  distribution.     It  is,  of  course,  evident  that  tendon  trans- 


DEFORMITIES  OF  THE  FOOT  841 

plantation  is  essentially  a  palliative  rather  than  a  curative  oper- 
ation. In  selected  cases  in  which  the  attachment  is  directly 
to  the  bone,  and  especially  when  lateral  motion  is  checked  by 
arthrodesis,  the  results  are  very  satisfactory.  The  improvement  in 
functional  ability  is  immediately  shown  in  the  improved  circula- 
tion and  size  of  the  limb.  In  some  cases  of  this  class  the  trans- 
ferred muscle  apparently  undergoes  an  adaptive  hypertrophy. 
It  is  needless  to  say  that  such  results  are  favored  by  massage 
and  by  appropriate  exercises.  Even  in  those  cases  in  wliich 
the  result  is  far  from  satisfactory,  some  improvement  is  usiudly 
apparent. 

The  principles  of  tendon  transplantation  may  be  applied  in 
other  situations.  For  example,  the  trapezius  may  replace  the 
deltoid  (page  618),  the  sartorius  or  the  tensor  vaginpe  femoris 
muscle  may  be  attached  to  the  tendon  of  a  paralyzed  Cjuadriceps 
extensor  muscle  for  the  purpose  of  restoring  in  some  degree  the 
ability  to  extend  the  leg  (page  619). 

The  flexor  muscles  may  be  transplanted  to  the  extensor  aspect 
of  the  thigh  to  overcome  persistent  contracture,  the  result  of 
spastic  paralysis  (page  632). 

The  operations  for  the  relief  of  hemiplegic  deformity  of  the 
hand  have  been  mentioned  (page  630). 

Tendon  Splicing.— Division  and  overlapping  of  the  tendons  of 
paralyzed  muscles  may  be  employed  with  advantage  in  certain 
instances.  For  example,  in  complete  paralysis  of  all  the  dorsal 
flexors  of  the  foot,  each  tendon  may  be  shortened  and  attached 
to  the  anterior  ligament;  thus  the  toe-drop  may  be  remedied  or 
reduced  to  such  an  extent  that  the  deformity  may  interfere  but 
slightly  with  locomotion.  As  a  rule,  however,  apparatus  must 
be  employed  to  prevent  a  recurrence  of  the  deformity  unless  it  be 
combined  with  arthrodesis. 

Arthrodesis. 

The  removal  of  the  cartilaginous  surfaces  of  articulating  irones 
and  thus  inducing  anchylosis  for  the  relief  of  paralytic  deformi- 
ties of  the  foot,  was  first  performed  by  Albert,  of  Vienna,  in  1S7N. 
As  applied  to  the  foot,  it  is  of  special  service  in  those  cases  in  which 
practically  no  muscular  power  remains,  the  so-called  dangle-foot. 
It  may  be  of  service,  also,  in  cases  of  less  disability,  as  in  oquiuus 
or  calcaneus,  when  the  patient  is  unable  to  provide  himself  with 
apparatus  or  desires  to  dispense  with  it. 


842  ORTHOPEDIC  SURGERY 

The  operation  consists  in  opening  the  joint  and  removing  the 
cartilage  from  the  apposed  surfaces  of  the  bones,  then  sewing 
them  to  one  another,  or  simply  fixing  the  parts  in  a  plaster  bandage 
until  union  has  taken  place.  If  the  case  is  one  of  simple  calcaneus 
or  equinus,  without  lateral  deviation,  the  operation  may  be  limited 
to  the  ankle-joint,  which  may  be  opened  from  the  back  or  front 
side,  as  seems  preferable.  As  has  been  stated,  the  usual  incision 
is  about  two  inches  in  length  over  the  front  of  the  ankle-joint. 
The  foot  is  then  plantar  flexed  and  the  cartilage  is  thoroughly 
removed  from  the  articulating  surfaces  with  a  thin  chisel  or  knife. 
The  lateral  incision  as  used  for  the  removal  of  the  astragalus  allows 
a  more  thorough  inspection  of  the  joint  and  in  many  instances  it  is 
to  be  preferred.  The  wound  is  then  closed,  and  the  denuded  bones 
are  forced  into  accurate  apposition  and  fixed  by  a  plaster  bandage. 
As  soon  as  possible  the  patient  is  encouraged  to  use  the  foot.  As 
a  rule,  in  cases  of  complete  paralysis  of  the  anterior  group  simple 
anchylosis  at  the  ankle-joint  is  not  sufficient  to  prevent  the  toe- 
drop,  and  it  is  well  to  destroy  the  mediotarsal  joint  also.  A 
convenient  method  is  to  remove  the  cartilaginous  surface  of 
the  astragalonavicular  and  calcaneocuboid  articulations,  together 
with  a  thin  wedge  of  bone,  base  uppermost.  In  some  instances 
the  tendons  of  the  paralyzed  muscles  are  shortened  to  aid  in  re- 
taining the  foot  in  the  improved  position.  This,  however,  is  of 
minor  importance.  The  operation  should  be  performed  under 
the  Esmarch  bandage,  and  the  limb  should  be  elevated  for  a  time 
to  prevent  the  subsequent  bleeding  from  the  bones. 

The  improvement  in  the  gait,  obtained  by  the  rectification  of 
deformity,  and  by  fixation  of  the  foot,  after  arthrodesis,  is  often 
verv"  marked,  and  in  many  instances  support  may  be  discarded; 
but,  in  early  childhood  at  least,  the  patients  should,  if  possible, 
be  kept  under  observation,  in  order  that  recurrence  of  deformity 
may  be  prevented. 

Arthrodesis  is  also  performed  at  the  knee  and  at  the  elbow- 
joints  and  wrist-joints  for  the  purpose  of  fixing  the  part  in  a  useful 
attitude.  The  operation  is,  of  course,  limited  to  cases  of  hopeless 
paralysis,  and  it  is  more  satisfactory  to  the  older  than  the  younger 
class  of  patients,  because  the  liability  to  recurrence  of  deformity 
is  less.  Arthrodesis  at  the  shoulder-joint  is  of  service  when  the 
humeroscapular  muscles  are  paralyzed,  especially  in  those  cases 
in  which  the  muscles  that  move  the  scapula  retain  their  power, 
since  anchylosis  adds  to  the  effectiveness  of  the  arm  nuiscles. 
The  joint  may  be  opened  by  an  incision  along  the  anterior  lower 


DEFORMITIES  OF  THE  FOOT  843 

border  of  the  deltoid.  The  cartilaginous  surfaces  are  removed, 
and  the  humerus  is  then  fixed  in  close  contact  with  the  glenoid 
surface  of  the  scapula  by  a  drill  or  by  sutures  until  union  is  firm. 
In  most  instances,  however,  the  transplantation  of  the  trapezius 
muscle  is  to  be  preferred. 


INDEX. 


Abduction,   forcible,  in  treatment  of 
coxa  vara,  560 
of  fracture  of  neck  of  femur,  562 
persistent,  in  weak  foot,  692 
Abscess  complicating  Pott's  disease, 
29 
pelvic,    in    tuberculous   disease    of 

spine  in  lower  region,  45 
in  tuberculous  disease  of  hip-joint, 
378 
significance  of,  379 
treatment  of,  380 
of  knee-joint,  426 
treatment  of,  426 
Absence  of  clavicle,  232 
of  patella,  443,  444 
of  ribs,  231 
of  vertebra?,  231 
Achillobursitis,  730 
anterior,  730 
etiology  of,  730 
pathology  of,  731 
posterior,  732 
symptoms  of,  730 
treatment  of,  731 
Achillodynia,732.    See  Achillolnirsitis. 
Achondroplasia,    505.     See   Chondro- 

dystrophia. 
Acquired  cerebral  paralvsis  of  child- 
hood, 623 
displacement  of  patella,  444 
genu  recurvatum,  440 
luxation  of  clavicle,  236 
talipes,  755,  813 
calcaneovalgus,  830 
treatment  of,  830 
calcaneoA'arus,  830 
treatment  of,  830 
calcaneus,  822 

deformitv  in,  development  of, 

823 
symptoms  of,  823 
treatment  of,  824 
Judson  brace  in,  824 
operative,  825 

Whitman's  operation  in,  828 
Willett's  operation  in,  82(J 
defonuity  in,  development  of,  81J 
diagnosis    of,    differential,    from 
congenital  talipes,  815 


Acquired  talipes  equinovalgus,  831 
treatment  of,  832 
equino varus,  831 

treatment  of,  831 
equinus,  815 
etiology  of,  816 
sjTnptoms  of,  817 
treatment  of,  818 
arthrodesis  in,  821 
immediate  correction  of  de- 
formity in,  818 
Thomas'  wTench,  819 
tonic  effect  of,  820 
manipulation  in,  818 
Shaffer  extension  shoe  in,  818 
etiology  of.  813 
simple  valgus,  832 
torticollis,  642,  648 
Acromegalia,  513 

diagnosis  of,  513 
Actinomycosis  of  spine,  128 
Active  congestion  in  treatment  of  joint 

disease,  262 
Acute  anterior  poliomyelitis,  598 
epiphysitis  at  hip-joint,  399 
infectious  arthritis  of  hip-joint,  399 
osteomyelitis,  277 
suppurative  arthritis  in  infancy,  274 
synovitis  of  knee,  424 
tenosynovitis  at  wrist-joint,  480 
tuberculous  arthritis,  276 
Adolescents,  kyphosis  of,  140,  226 
Adults,  traumatic  coxa  vara  in,  565 

tuljerculous  hip  disease  in,  377 
Amputation   in   treatment   of   tuber- 
culous disease  of  knee-joint.  430 
in  tuberculous  disease  of  hip-joint, 
388 
Anchvlosis,  293 
etiologv  of,  293 
pathology  of,  293 
prevention  of,  293 
treatment  of.  293 

forcible  correction  in.  295 
operative  exploration  in,  296 
passive  motion  in,  294 
Ankle,  sprain  of,  459 
chronic,  462 

treatment  of.  462 
s\niiptoms  of,  459 
treatment  of,  459 
strapping  in,  460 


846 


INDEX 


Ankle-joint,     arthritis   of,   infectious, 
465 
diseases  and  injuries  of,  449 
other  affections  of,  465 
tenosATiovitis  at,  463 
treatment  of,  463 
tuberculous,  464 
disease  of,  449 

agQ  at  incipiency  of,  450 
statistics  of,  450,  451 
astrasalohavicular    disease  in, 

453 
defonnity  in,  452 

reduction  of,  455 
cUagnosis  of,  453 
etiology-  of,  450 
pathologj'  of,  449 
physical  examination  in,  452 
prognosis  in,  457 

statistics  of,  457 
situation  of,  450 

statistics  of,  450 
statistics  of,  449 
subastragaloid  disease  in,  453 
s}Tnptoms  of,  451 
treatment  of,  455 
operative,  456 
Ankles  sweUing  about,  465 
Anterior  curvature  of  tibia,  595 
dislocation  at  hip-joint,  524 
displacement    of    tibia,    442.     See 

Genu  recurvatum,  congenital, 
metatarsalgia,  721 
pohomj^elitis,  acute,  598 
age  of  onset  in,  599 

statistics  of,  599 
deformities  of  neck  in,  607 
deformity  in,  604 
reduction  of,  616 
secondary,  608,  609 
of  trunk  in,  607 
of  upper  extremit}',  607 
diagnosis  of,  601 

from  diphtheritic  paralysis, 

603 
from  joint  disease,  602 
from  multiple  neuritis,  602 
from    obstetrical    paralysis, 

603 
from  other  forms  of  spinal 

paralysis,  602 
from    paralysis    of    cerebral 

origin  in  childhood,  602 
from     Pott's     paraplegia, 

602 
from  pseudoparalysis,  603 
from  rheumatism,  002 
from  spastic  spinal   paraly- 
sis, 602 
etiology  of,  599 

paralysis  of  different  muscles 
in,  effect  of,  upon  function, 
604 
distribution  of,  600 


Anterior  poliomyelitis,  acute,  pathol- 
ogy of,  59S 
prognosis  in.   603 

electrical  test  in,  603 
retardation  of  growth  in,  60S, 

609 
s^Tnptoms  of,  600  . 
treatment  of,  610 

mechanical,  principles  of,  610 
operative,  616 

arthrodesis  in,  620 
Hoffa's,    for    paralysis    of 

deltoid  muscle,  618 
nerve  grafting  in,  620 
osteotomy  in,  620 
reduction  of  deformity  in, 

16 
tendon  transplantation  in, 

618 
transplantation     of     Sar- 
torius  muscle  in,  619 
of  paralysis  of  anterior  mus- 
cles of  leg,  610 
of  posterior  muscles  of  leg, 
611 
of  arm,  616 
of  muscles  of  hip,  614 
of  paralj'tic  scoliosis,  616 
of  thigh  muscles,  612 
Anteroposterior  contour   of   spine  in 
lateral  curvature,  155 
deformities  of  spine,  224 
kvphosis,  224 

'  treatment  of,  226 
lordosis,  228 

treatment  of,  229 
Aran-Duchenne   type   of   progressive 

muscular  atrophj-,  633 
Arborescent  synovial  tuberculosis,  255 
Arm,  paralysis  of,  obstetrical,  482 

treatment  of,  483 
Arthrectomy  in  treatment  of  tuber- 
culous disease  of  knee- 
joint,  427 
results  of,  428 
Arthritis  of  ankle-joint,  infectious,  465 
atrophic,  284 

complicating  diphtheria,  273 
infectious  diseases,  273 
prognosis  in,  273 
treatment  of,  27 
scarlatina,  273 
typhoid  fever,  273 
deformans,  403 
symptoms  of,  404 
treatment  of,  404 
gonoj-rhceal,  270 
distribution  of,  270 
in  infancy,  272 
symptoms  of,  270 
treatment  of,  272 
varieties  of,  271 
of  hip-joint,  acute,  399 
symptoms  of,  399 


INDEX 


847 


Arthritis  of  hip-joint,    acute,    treat- 1 
ment  of,  399 
gonorrhoBal,  401 
subacute,  400 
in  infancy,  acute,  274 
puerperal,  272 
rheumatoid,  284 
of  spine,  infectious,  133 
of  suboccipital  region  of  spine,  133 
suppurative,  in  infancj',  274 
etiology  of,  274 
prognosis  of,  275 
symptoms  of,  275 
treatment  of,  275 
tuberculous,  acute,  276 
Arthrodesis,  620 

in  paralytic  talipes,  841 
in    treatment  of    acquired  talipes 
equinus,  821 
Arthrotomy  in  congenital  dislocation 

at  hip-joint,  542 
Articulation,  sacroiliac,  injury  of,  148 
Articulations  of  upper  extremity,  dis- 
eases and  injuries  of,  466 
Astragalectomv  in  treatment  of  neg- 
lected talipes,  800 
Astragalonavicular  disease,  453 
As\aiimetrical  development  of  bod\', 

236 
Ataxia,  hereditary,  636 
Atrophic   arthritis,   284.     *See   Pkheu- 

matoid  arthritis. 
Atrophy  of  bone,  244 

muscular,  myelopathic  form  of,  633 

progressive,  633 
in  tuberculous  disease  of  hip-joint, 
313 
Brackett's  statistics  in,  314 
causes  of,  314 
Attitude,  change  in,  in  Pott's  disease, 
28 
rhachitic,  131,  502 
in  treatment  of  weak  foot,  699 
in  tuberculous  disease  of  spine  in 
lower  region,  39,  40 


B 


Back,  flat,  224 

hollow  round,  223,  224 

knee,  440.     See  Genu  rccurvatum. 

pain  in  lower  portion  of,  142 

treatment  of,  143 
round,  223 
Bandage,    plaster,    in    treatment    of 
tuberculous  disease  of  knee-joint, 
417 
of  hip-joint,  of  spine.     See    Spicas, 
plaster  jacket,  etc. 
Baseball  finger,  496 
Bier's  treatment  of  tuberculous  dis- 
ease of  knee-joiut,  425  j 
Bilateral  coxa  vara,  555 


Bilateral  dislocation  at  hip-joint,  523 

hip  disease,  375 
Billroth  splint  in  treatment  of  tuber- 
culous disease  of  knee-joint,  419 
Body,  asymmetrical  development  of, 
"236 
lateral  inclination  of,  in  tuberculous 
disease  of  spine  in  lower  region,  41 
Bone,  atrophy  of,  244 
hypertrophy  of,  245 
Bones  and  joints  of  lower  extremity, 
deformities  of,  569 
operation    on,  in    treatment    of 

neglected  talipes,  800 
tuberculous  disease  of,  246 
Bow-leg,  569 
anterior,  595 

symptoms  of,  595 
treatment  of,  597 
attitude  of  rest  in,  572 
deformity  in,  measurement  of,  591 
outgrowth  of,  572 
predisposition  to,  570 
symptoms  of,  591 
time  of  onset  of.  570 
treatment  of,  592 
by  braces,  592 
expectant,  592 
operative,  594 
Brace,  anterior  shoulder,  77 

caliper,  in   treatment   of   tubercu- 
lous disease  of  knee-joint,  420 
Judson's,  in  treatment  of  acquired 
tahpes  calcaneus,  824 
of  infantile  club-foot,  773 
Knight  spinal,  217 
in  lateral  curvature  of  spine,   216 
retention,  in  treatment  of  infantile 

club-foot,  777 
Taylor,    in   treatment   of   infantile 
club-foot,  777 
of  Pott's  disease,  76 
Thomas'    knee,    in    treatment    of 
tuberculous  disease  of  knee-joint, 
420 
in  treatment  of  bow-leg,  592 
of  infantile  club-foot,   773 
of  knock-knee,  585 
of  lateral  curvature  of  spine,  216 
of  weak  foot,  703 
Whitman's,  in  treatment  of  weak 
foot,  703  _  I 

Brachial  plexus,  obstetrical  injury-  to, 

repair  of,  487 
Bunion,  744 

Bursa,  prctibial,  enlargement  of  super- 
ficial, 440 
Bursa?  and  cysts  in  popliteal  region, 

440 
Bursitis,  gluteal,  402 
iliopsoas.  402 
prepatellar,  439 

treatment  of,  439 
pretibial,  439 


848 


INDEX 


Bursitis,  pretibial,  s\anptoms  of.  439 
treatment  of,  440 
at  shoulder-joint,  chronic,  479 
treatment  of,  403 


CALCAXEOBrRSITIS,  733 

treatment  of,  734 
Caput  ciuadratum  in  rhachitis,  500 
Carcinoma  of  femur.  403 

of  spine,  126 
Caries,  dr^-,  256 

sicca,  256 
Cerebral  paralysis  of  childhood,   623 
acquired,  623 

deformities  in,  62S 
disabiUty  in.  62S 
loss  of  growth  in,  62S 
paralysis  in,  627 
congenital,  623 
paralysis  in,  626 
weakness  in,  626 
deformities  in,  627 
distribution  in,  623 
statistics  of,  623 
etiology  of,  623 
of   intrauterine  origin,  624 
occurring  during  labor,  624 
pathology  of,  623 
symptoms  of,  general,  625 
mental,  626 
motor,  625 
treatment  of,  629 
of  hemiplegia,  629 
of  paraplegia,  631 
Cervical  opisthotonos,  663 

ribs,  231 
Charcot's  disease,  290 
diagnosis  of,  292 
distribution  of,  291,  292 
pathology  of,  291 
symptoms  of,  292 
treatment  of,  292 
Chest,  deformities  of,  232 
fiat,  232 

treatment  of,  232 
funnel,  235 

minor  deformities  of,  235 
pigeon,  233 

treatment  of,  234 
Childhood,  cerebral  paralysis  of,   023 
osteomalacia  in,  509 
strains  and  injuries  of  knee    in,  434 
weak  foot  in,  694 
Chondrodyst rophia,  505 
etiology  of,  506 
pathology  of,  506 
prognosis  of,  506 
treatment  of,  506 
Chronic  bursitis  at  shoiiId'T-joint,  47 

synovitis  of  knee,  435 
Clavicle,  absence  of,  232 
acquired  luxation  of,  2.'^0 


Clavicle,  acquired  luxation  of,  treat- 
ment of,  236 
defect  of,  232 
subluxation  of,  236 
treatment  of,  236 
Club-foot,  congenital,  755 
anatomy  of,  756 
symptoms  of,  766 
treatment  of,  767 
Club-hand,  491 
etiologv  of,  491 
statistics  of,  492 
treatment  of,  493 
varieties  of,  491 
Compensatory    deformity   in    lateral 
curvature  of  spine,  165 
in  Pott's  disease,  28 
Congenital    and    acquired    affections 
leading  to  general  distortions,  498 
cerebral  paralysis  of  childhood,  623 
contraction  of  fingers,  494 
treatment  of,  494 
at  knee,  448 
deficiency  of  foot,  811 
deformities  of  elbow,  489 

of  foot  associated  with  defective 

development,  809 
at  knee,  447 
at  wrist,  491 
dislocation  at  hip-joint,  515 
anterior,  524 

symptoms  of,  524 
bilateral,  523 

symptoms  of,  523 
diagnosis  of,  524 
etiology  of,  520 
pathology  of,  516 
supracotyloid,  524 
symptoms  of,  521 

general,  523 
treatment  of,  526 
arthrotomy  in,  542 

description  of,  543 
in  infancy,  540 
Lorenz's  operation  in,  527 
description  of,  527 
prognosis  of,  537 
older  subjects,  539 
open  operation  in,  544 

description  of,  ,544 
of  osteotomy  in,  543 
palliative,  549 
reduction,  531 

in  two  sittings,  531 
in  the  young,  531 
variations  in,  540 
unilateral,  521 
symptoms  of,  521 
of  shoulder,  482 

reduction  of  deformity  in,  484 
displacement  of  patella,  444 

of  phalanges,  495 
elevation  of  scapula,  229 
genu  recurvatum,  442 
hypertrophy  of  foot,  811 


INDEX 


849 


Congenital  cedema  of  feet,  812 
subluxation  of  hip,  549 
talipes,  755 

calcaueovalgus,  808 
calcaneovarus,  808 
calcaneus,  807 
equinocavus,  808 
equinus,  807 
etiology  of,  756 
valgocavus,  808 
valgus,  807 
varus,  806 
torticollis,  642,  643 
weakness  in   cerebral  paralysis  of 
childhood,  623 
Constricting  bands  of  foot,  812 
Contracted  toot,  716 
etiology  of,  716 
symptoms  of,  717 
treatment  of,  719 
operative,  720 
Contraction,  Dupuytren's,  496 
etiology  of,  496 
pathology  of,  496 
symptoms  of,  497 
treatment  of,  497 
at  knee,  congenital,  448 
psoas,  in     tuberculous    disease    of 
spine  in  lower  region,  40 
Coxa  valga,  568 
vara,  550 
bilateral,  555 

defomiity  in,  mechanical  predis- 
position to,  551 
diagnosis  of,  556 
etiology  of,  551 
other  varieties  of,  556 
pathology  of,  550 
sjanptoms  of,  553 

mechanical  effects,  553 
physical  effects,  554 
traumatic,  562 
in  adult  life,  565 
treatment  of,  563 
treatment  of,  558 
operative,  560 

cuneiform      osteotomy      in, 

560 
forcible  abduction  in,  560 
linear  osteotomy  in,  560 
Cramp,  nuiscular,  of  leg,  434 
Craniotabes  in  rhachitis,  500 
Crepitus,  scapular,  236 
Cretinism,  506 
Cubitus  valgus,  489 
in  rhachitis,  501 
varus,  489 

in  rhachitis,  501 
Cuneiform  osteotomy  in  treatment  of 
anterior  bow-leg,  597 
of  coxa  vara,  560 
of  knock-knee,  589 
of  neglected  talipes,  800 
Curvature  of  spine,  lateral,  149 


Cysts,  bursae  and,  in  popliteal  region, 
440 
of  femur,  403 


Defect  of  clavicle,  232 
Deformity    in    acquired    talipes,    de- 
velopment of,  814 
in  acute  anterior  poliomyelitis,  604 

reduction  of,  616 
of  bones  of  lower  extremity,  569 
in  bow-leg,  measurement  of,  591 
outgrowth  of,  572 
predisposition  to,  570 
in  cerebral  paralysis  of  childhood, 

627 
of  chest,  232 
minor,  235 
compensatory,  in  lateral  curvature 
of  spine,  165 
in  Pott's  disease,  29 
correction  of,  by  femoral  osteotomy 
in    tuberculous    disease   of    hip- 
joint,  390 
in    coxa   vara,    mechanical   predis- 
position to,  551 
development  of,  in  acquired  talipes, 
814 
calcaneus,  823 
of  elbow,  congenital,  489 
of  foot,  665,  752 

compound,  753 
functional  pathogenesis  of,  238 

Wolff's  law  of,  238 
hysterica],  638 
at  knee,  congenital,  447 
in    knock-knee,    measurement    of, 
581 
outgrowth  of,  572 
predisposition  to,  570 
secondary,  578 
in  lateral  curvature  of  spine,  172 

prevention  of,  179 
of  legs  with  weak  foot  in  childhood, 

695 
and  malformations  of  knee,  443 
of  neck  in  acute  anterior  poliomy- 
elitis, 607 
of  other  parts  caused  by  tubercu- 
lous disease  of  hip-joint,  396 
overcorrection  of,  in  torticollis,  655 
in  Pott's  disease,  17 
compensatory,  28 
muscular,  28 
rapid  correction  of,  in  treatment  of 

neglected  talipes,  781 
rectification  of,  in  treatment  of  in- 
fantile talipes,  768 
reduction   of,    in    congenital   dislo- 
cation of  shouldiT,  484 
in  resistant  cases  of  tubercuolus 
disease  of  hip-joint,  388 


54 


850 


ind:ex 


Deformity,  reduction  of,  in  treatment 
of  tuberculous   disease  of   knee- 
joint,  417 
in  rhacliitis,  500 

secondar\',  of  acute  anterior  polio- 
myelitis, 60S.  609 
in  neglected  talipes,  789 
of  spine,  anteroposterior,  224 
SprengeFs,  229 

of  trunk  in  acute  anterior  poliomye- 
litis, 607- 
in    tuberculous    disease    of    ankle- 
joint,  452 
reduction  of,  455 
of  upper  extremity,  482 

in  acute  anterior  poliomyelitis, 
607 
in  weak  foot,  679 
at  wrist,  congenital,  491 
Deyiation,  lateral,  in  lateral  curyature 

of  spine,  151 
Diagnosis  of  acute  anterior  poliomy- 
elitis, 601 
of  Charcot's  disease,  292 
of    congenital    dislocation    of    hip- 
joint,  524 
of  coxa  yara,  556 

differential,  between  congenital  and 
acquired  taUpes,  815 
of  lumbar   Pott's  disease  in  in- 
fancy, 50 
from  acute  rhachitis,  50 
from  scuryy,  50 
of  tuberculous  disease  of  spine, 
46-65 
of  disease  of  spine,   landmarks  in, 

34 
of  hysterical  hip,  637 
of  lateral  curyature  of  spine,  174 
mobility  in,  175 
posture  in,  174 
of  malignant  disease  of  spine,  127 
of  sacroiliac  disease,  146 
of  torticollis,  651 

of  tuberculous    disease    of    ankle- 
joint,  453 
of  bones  and  joints,  259 
of  hip-joints,  326 
of  knee-joints,  415 
of  spine,  65 
of  typhoid  spine,  132 
of  weak  foot,  687 
Disabilities  of  foot,  665 
Diseases  and  injuries  of  ankle-joint, 
449 
of  articulations  of  upper  extrem- 
ity, 466 
Dislocation  of  hip-joint,  spontaneous, 
400 
of  shoulder,  congenital,  482 
rf!current,  487 
treatment  of,  487 
Displacement  of  peronei  tendons,  7'16 
treatment  of,  740 


Distortions  of  fingers,  495 

of  limb   in  tuberculous  disease   of 

hip-joint,  307 
rhachitic,  general,  598 
Doigt  a  Ressort,  495 
Drop-finger,  496 
Dry  caries,  256 
Dupuytren's  contraction,  496 

etiology  of,  497 

pathology  of,  496 

symptoms  of,  -197 

treatment  of,  497 
Dj^sbasia  angiosclerotica,  735 
Dystrophy,  muscular,  634 


Effusion  at  knee,  quiet,  438 
Elbow,      deformities      of,      acquired, 
489 
congenital,  489 
Elbow-joint,   tuberculous   disease   of, 
470 
•age  at  incipiency  of,  470 

statistics  of,  470 

pathology  of,  470 

symptoms  of,  471 

treatment  of,  471 

excision  in,  473 

operative,  473 

reduction    of    deformity    in, 
473 
Electrical  test  in  prognosis  of  acute 

anterior  poliomyelitis,  603 
Elongation    of    ligamentvmi    patella?, 
447 
etiology  of,  447 
symptoms  of,  447 
treatment  of,  447 
Enlargement   of   superficial   pretibial 

bursa,  440 
Epiphysitis  at  hip-joint,  acute,  399 
symptoms  of,  399 
treatment  of,  399 
Erythromelalgia,  734 
Excision  of  hip-joint  in  tuberculous 
disease,  384 
in  treatment  of  tuberculous  disease 
of  knee-joint,  428 
results  of,  429 
Exercise  in  treatment  of  knock-knee, 
583 
of  lat(;ral  curvature  of  spine,  184, 
200 
in  nuisclc  building,  207 
of  weak  foot,  699 
Exostoses  of  foot,  746 
Extra-articular      hip-joint      disease, 
401 
iiibcrcnlous   disease   of   knee-joint, 
126 
operative  intervention  in, 426 
treatment  of,  42(5 


INDEX 


851 


P 


Femur,  bending  of  neck  of,  550.     See 
Coxa  vara, 
carcinoma  of,  403 
cysts  of,  403 
depression    of    neck    of,    550.     See 

Coxa  vara, 
fracture  of  neck  of,  5G2 

in  adult  life,  565 
incurvation   of  neck  of,   550.     See 

Coxa  vara, 
partial   separation   of  epiphysis  of 

head  of,  in  adolescence,  565 
sarcoma  of,  403 
and  tibia,  changed  relations  of,  in 

knock-knee,  578 
traumatic   separation   of   epiphysis 
of  head  of,  564 
Finger,  baseball,  496 

contraction  of,  congenital,  494 

treatment  of,  494 
distortions  of,  495 
drop-,  496 
jerking,  495 
etiology  of,  495 
treatment  of,  496 
mallet,  496 
snapping,  495 
etiology  of,  495 
treatment  of,  496 
trigger,  495 

etiology  of,  495 
treatment  of,  496 
webbed,  495 
etiology  of,  495 
treatment  of,  495 
Flat  back,  224 

chest,  232 
Foetal  rhachitis,  505 
Foot  in  activity,  668 
arches  of,  665 

club-,  non-deforming,  716.  (SVe  Con- 
tracted foot, 
considered  as  a  mechanism,  076 
constricting  bands  of,  812 
contracted,  716 
etiology  of,  716 
symptoms  of,  717 
treatment  of,  719 

operative,  720  j 

deficiency  of,  congenital,  811  : 

deformities  of,  752 

compound,  753  i 

congenital,    associated    with    de-     1 
fective  development,  809 
disabilities  and  deformities  of,  665      [ 
(>xostoses  of,  746  ! 

flat-,  679 

functions  of  muscles  of,  675  !  I 

general  (lesciiption  of,  and  its  func- 
tions, ()()5 
iiollow,  716 

li>l)crtrophy  of,  congenital,  811  !■ 

improper  postiu'es  of,  669  !• 


Foot,  movements  of,  670 
oedema  of,  congenital,  812 
as  a  passive  support,  667 
splay-,  679 
tables  of  relative  strength  of  muscles 

of,  676 
weak,  679 

in  childhood,  694 
symptoms  of,  694 
weak  ankles  in,  694 
deformity  of  legs  witli,  695,  697 
general  weakness  in,  695 
irregular  forms  of,  695 
outgrown  joints  in.  695 
out-toeing  and  in-toemg  in,  694 
diagnosis  of,  687 
attitudes  in,  687 
bearing  surface  in,  689 
contour  in,  688 
distribution     of     weight     and 

strain,  687 
range  of  motion  in,  089 
etiology  of,  683 
extreme  types  of,  692 
persistent  abduction,  692 
pes  planus,  692 
limitation   of   motion    and   mus- 
cular spasm  in,  692 
pathology  of,  683 
rigid,  706 

functional  use  in  overcorrected 

attitude,  708 
treatment  of,  706 
adjuncts  in,  713 
forcible  overcorrection  in, 707 
operative,  714 
plaster  strapping  in,  713 
systematic  manipulation  in, 
'709 
.Thomas',  713 
varieties  of,  712 
symptoms  of,  685 
treatment  of,  697 
attitudes  in,  699 
brace  in,  703 

construction  of,  701 
positive  action  of,  704 
exercises  in,  699 
plaster  cast  in,  702 
raising  inner  border  of  shoe  in, 

699 
the  shoe  in,  698 
support  in,  700 
varieties  of,  ()91 
'orcii)le    ai)duetion    in    treatment    of 
coxa  \ara,  560 
correction    by    reverse    leverage    in 
treatment  of  tul)erculous  disease 
of  knee-joint,  418 
'racture  of  metatarsiil  i)ones,  746 
of  neck  of  fenuir,  562 
in  aihilt  life,  5(i5 
of  spine,  129 
ragilitas  ossium,  507 
Viedrcich's  disease,  63(» 


852 


INDEX 


Function,    impairment   of,    in   Pott's 

disease,  28 
Functional  affections  of  joints,  630, 
639 
pathogenesis  of  defonnitv,  238 

Wolff's  law  of,  238 
residts  of  treatment  of  tuberculous 
disease  of  tup-joint,  432 
Fminel  chest,  235 


G 


Gait  in  tuberculous  disease  of  spine  in 

lower  region,  39 
General  rhachitic  distortions  of  lower 

limbs,  597 
Genu  recur\-atmn,  acquired,  440 
etiology  of,  441 
symptoms  of,  441 
treatment  of,  442 
congenital,  442 
etiology  of,  443 
treatment  of,  443 
valgum,  deformity  in,  outgrowth  of, 
572 
etiology  of,  570 
pathology  of,  581 
time  of  onset,  570 
treatment  of,  583 
expectant,  583 
operative,  587 
unilateral,  580 
varum,  590 

deformitj^  in,  outgrowth  of,  572 
sj-mptoms  of,  591 
time  of  onset  of,  570 
treatment  of,  592 
by  braces,  592 
expectant,  592 
operative,  594 
Ghiteal  bursitis,  402 
Gonorrheal  arthritis,  270 
distribution  of,  270 
of  hip-joint,  401 
in  infancy,  272 
purulent  form  of,  271 
sfirofibrinous  form  cjf,  271 
serous  form  of,  271 
symptoms  of,  270 
treatment  of,  272 
rheumatism,  270.     *SVe  Gonorrlineal 
arthritis, 
of  spine,  133 
Gfjut,  288 

Growtli,  retardation   of,  in    i)aralytic 
affections,  025 
in  tiil)(!rciii()iis  disease  of  hip-joint, 
317 


H 


HyEMAHTHHOHI.S,  290 

Ha;matoma  of  steniotiiastoid  muscle, 
046 


Haemophilia,  289 

treatment  of,  290 
Hallux  flexus,  735 
rigidus,  735 

etiology  of,  736 
treatment  of,  736 
valgus,  740 

etiology  of,  741 
pathology  of,  740 
symptoms  of,  741 
treatment  of,  741 
operative,  742 
varus,  738 

treatment  of,  739 
Hammer-toe,  744 
symptoms  of,  745 
treatment  of,  745 
Harrison's  groove  in  rhachitis,  500 
Heberden's  nodosities  in  osteoarthri- 
tis, 283 
Heel,  painful,  733 

treatment  of,  734 
Hemorrhage  into  joints,  289,  290 
Hereditary  ataxia,  636 
High  hip  in  lateral  curvature  of  spine, 
156 
shoe  in  treatment  of  lateral  curva- 
ture of  spine,  221 
shoulder    in    lateral    curvature    of 
spine,  156 
Hip,  change  in  contour  of,  in  tuber- 
culous disease  of  hip-joint,  313 
disease,  298 
hysterical,  637 
snapping,  549 

subluxation  of,  congenital,  549 
Hip-joint,  acute  epiphysitis  at,  399 
infectious  arthritis  of,  399 
disease,  extra-articular,  401 
dislocation  at,  congenital,  515 
anterior,  524 

symptoms  of,  524 
bilateral,  523 

symptoms  of,  523 
diagnosis  of,  524 
etiology  of,  520 

hereditary  influence  in,  520 
pathology  of,  516 
supracotyloid,  524 
symptoms  of,  521 

general,  523 
treatment  of,  526 
arthrotomy  in,  542 

description  of,  543 
in  infancy,  540 
Lorenz;,  description  of,  527 
operation  in,  527 
prognosis  of,  537 
okh-r  subjects,  539 
o[)en  o])eration  in,  544 
description  of,  514 
statistics  (jf,  5K) 
ostiHjtomy  in,  513 
palliative,  549 


INDEX 


853 


Hip-joint,  dislocation  at,   congenital, 
treatment  of,  reduction, 
531 
in  two  sittings,  531 
in  young,  531 
variations  in,  540 
unilateral,  521 
symptoms  of,  521 
excision  of,  in  tuberculous  disease, 

384 
gonorrhoea!  arthritis  of,  401 
malignant  disease  of,  403 
non-tuberculous  affections  of,  398 
osteoarthritis  of,  403 
symptoms  of,  404 
treatment  of,  404 
spontaneous  dislocation  of,  400 
subacute  arthritis  of,  400 
traumatisms  at,  398 
treatment  of,  398 
tuberculous  disease  of,  298 
abscess  in,  378 

significance  of,  379 
treatment  of,  380 

exploratory  operations  in, 
382 
actual  lengthening  of  liml)  in, 
318 
shortening  of  limb  in,  316 
in  adult,  377 
age  at  incipiency,  302 
amputation  in,  388 
bilateral,  375 

treatment  of,  376 
causes  of  death,  392 
combined  with  disease  of  other 

parts,  376 
correction     of     deformity     by 

femoral  osteotomy,  390 
details  of  1000  cases  of,  330 
diagnosis  of,  differential,  326 
distortion  of  limb  in,  307 

apparent  lengthening,  307 
shortening,  310 
examination  in,  method  of,  320 

physical,  320 
excision  of  hip  in,  384 
Koenig's  method  of,  384 
statistics  of,  386,  387 
table  of  functional  results  of, 
387 
history  of  case  of,  320 
in  infancy,  377 
Koenig's  statistics  of,  310 
local  signs  of,  325 
measurements  in,  321 
method  of  estimating  degree  of 
distortion  of  limb 
in,  322 
Kingsley's     table, 

325 
Lovett's  table,  323 
of  recording  case  of,  329 
formulae  used,  330 


Hip-joint,     tuberculous     disease     of, 
mortality  in,  391 
natural  cure  in,  310 
prognosis  of,  391 

as  to  function,  394 
reduction  of  defonnity  in  re- 
sistant cases  of,  388 
sex  affected  in,  302 
side  affected  in,  303 
sinuses  in,  382 

treatment  of,  382 
symptoms  of,  303 
atrophy  as,  313 
change  in  contour  of  hip  as, 

313 
distortion  of  limb  as,  307 
general,  319 
debility  319 
fever,  320 
limp  as,  303,  304 
night  cry  as,  304 
stiffness  as,  305 
treatment  of,  332 

application  of  plaster  spica 

bandage  in,  350 
during  stage  of  recovery,  371 
immediate  reduction  of  de- 

formit}'  in,  353 
Lorenz  spica  bandage  in,  351 
mechanical,  333 

application      of     traction 

splint  in,  338 
high  shoe  in,  338 
perineal  bands  in,  338 
splinting  in,  334 
Taylor's  method  of  trac- 
tion in,  336 
traction     hip    splint    for, 
334 
plasters  in,  336 
straps  for,  336 
by  plaster  bandage,  349 
practical      combination     of 
traction,    splinting ,     and 
stilting  in,  361 
reduction    of   deformity    in, 
immediate,  353 
lateral  traction  in,  358 
by  Thomas'  method,  346 
by  traction  brace  in,  340 
by  weights  and  pulleys, 
350 
Marsh's     appliance 
for,  356 
relative  efficiency  of  traction 
hip  splint  in,  341 
and  sphnting  in,  359 
removal    of   direct    pressure 

in,  360 
stilting  in,  334,  360 
Thomas',  343 
brace  in,  344 

modifications  of  348 
traction  in,  334 


854 


INDEX 


Hoffa's  treatment  for  paralysis  of  del- 
toid muscle  in  acute  anterior  polio- 
myelitis, 61S 

Hollow  foot,  716.  See  Contracted 
foot. 

Hypertesthesia  of  skin  in  neurotic 
spine,  143 

Hyperplasia  of  fatty  tissue  -within 
knee-joint,  437 

Hypertrophy  of  bone,  245 

Hysterical  club-foot,  638 
deformities,  638 
hip,  637 

diagnosis  of,  637 
joint  affections  and  deformities,  636 
scoliosis,  638 
spine,  144 

symptoms  of,  145 
treatment  of,  145 


Idiopathic  osteopsathyrosis,  507 
Iliopsoas  bursitis,  402 
Incidental  lateral  curyature  of  spine, 
166 
synovitis  of  knee,  438 
Infancy,  acute  arthritis  in,  274 
gonorrhoeal  arthritis  in,  272 
lumbar  Pott's  di.sease  in,  peculiar- 
ities of,  50 
tuberculous  hip  disease  in,  377 
Infantile   paralysis,   598.     See  Acute 
anterior  poliomyelitis, 
scorbutus,  506 
pathology  of,  507 
symptoms  of,  507 
treatment  of,  507 
Infectious  arthritis  of  ankle-joint,  465 

osteomyelitis,  277 
Injuries,  diseases  and,  of  ankle-joint, 
449 
of  articulations  of  upper  extrem- 
ity 466 
of  knee,  437 

in  childhood,  434 
of  sacroiliac  articulation,  148 
of  spine,  12S 
of  tibial  tul)crclo,  440 
Ititcnriittcnt  hmp,  735 
Internal   derangeincnt   of   knee-joint, 

436 
Irregular  fonris  of  torticollis,  663 


.Ikrking  finger,  495 

Joint  afffrtioiis,  hysterical,  (J3(i 

tn^atmcnt  of,  638 
Joints,  bones  and,  tuberculous  disease 
of,  246 
double,  in  rhachitis,  500 


Joints,  functional  affections  of,  636 
hemorrhage  into,  289,  290 
inflammation  of,  gonorrheal  270 
neurotic,  639 

non-tuberculous  diseases  of,  266 
pelvic,  relaxation  of,  142 
syphilitic  diseases  of,  266 
treatment  of,  269 
pain  and  swelling  of,  267 
tuberculous  disease  of,  other  forms 
of,  254 
Judson's   brace   in   treatment   of   ac- 
quired talipes  calcaneus,  824 
of  infantile  club-foot,  773 


Kingsley's  table  for  estimating  de- 
gree of  .distortion  of  limb  in  tuber- 
culous disease  of  hip-joint,  325 
Knee,  back,  440.     See  Genu  recurva- 
tjim. 
contraction  at,  congenital,  448 
prognosis  of,  448 
treatment  of,  448 
deformities  at,  congenital,  447 
displacement  of  a  semilunar  carti- 
lage of,  436 
housemaid's,  439 
treatment  of,  439 
Knee-joint,  hyperplasia  of  fatty  tissue 
within,  437 
injury  of,  437 

in  childhood,  434 
loose  bodies  in,  436 
non-tubercvilous  affections  of,  434 
deformities  of,  434 
pathology  of,  406 
primary  distortions  of,  411 
prognosis  in,  431 
statistics  of,  431 
Gibney's,  431 
secondary  distortions  of,  412 
statistics  of,  409 

age  at  incipiency,  409 
on  course  and  outcome  of, 
431 
symptoms  of,  409 
synonyms  of,  406 
synovial  tuberculosis,  427 

treatment  of,  427 
treatment  of,  41(5 
accessory,  424 

IJier's  treatm(!nt  of,  425 
cautery  as,  424 
ichthyol  ointment  as,  424 
iodoform    emulsion    injec- 
tions as,  424 
.T-rays  as,  424 
amputation  in,  430 
arthroctomy  in,  427 
results  of,  428 
statistics  of,  428 


INDEX 


855 


Knee-joint,  non-tuborculous,  defornii- 
ties  of,  treatment  of,  Bill- 
roth splint  in,  419 
during  convalescence,  425 
excision  in,  428 
results  of,  429 
forcible     correction    by    re- 
verse leverage;  in,  418 
functional  results  of,  432 

statistics  of,  431 
mechanical,  420 

caliper  brace  in,  423 
Thomas'  knee  brace  in,  420 
operations  for  relief  of  final 

defonnity  in,  430 
plaster  bandage  in,  417 
reduction    of    deformity   in, 

417 
traction  in,  418 
malformations  of,  443 
other  deformities  of,  443 
quiet  effusion  at,  438 
snapping,  447 

treatment  of,  448  ,,  ' 

strains  of,  in  childhood,  434 
synovitis  of,  acute,  434 
causes  of,  435 
chronic,  435 
incidental,  438 
painless,  438 
recurrent,  435 
tuberculous  diseases  of,  406 
abscess  in,  426 

Koenig's  statistics  of,  426 
treatment  of,  426 
actual  lengthening  of  limb  in, 
414 
statistics  of,  414 
shortening  in,  414 
statistics  of,  432 
deformity  in,  432 

statistics  of,  432 
diagnosis  of,  415 

from  acute  epiphysitis,  415 
from  Charcot's  disease,  416 
from  hsemarthrosis,  415 
from  hysterical  joint,  416 
from  infectious  arthritis,  415 
I  from  injury  of  knee,  415 

1  from  osteoarthritis,  416 

from  rhevunatism,  416 
from    rheumatoid    arthritis, 

416 
from  sarcoma,  416 
\  from  synovitis,  415 

distortion  in,  primary,  411 

secondary,  412 
etiology  of,  409 
extra-articular,  426 

operative  intervention  in,  426 
trcatment^  of,  426 
mortality  in,  431 
causes  of,  433 
influence  of  age  on,  432 


Knee-joint,    tuberculous    diseases   of, 
mortality  in,  statistics  of,  431,  432 
Knock-knee,  569 

attitude  in,  accommodative,  587 

of  rest  in,  572 
changed  relation  of  femur  and  tibia 

in,  578 
combined  with  bow-legs,  580 

with  general  rhachitic  distortion, 
580 
deformity     in,    measurements    of, 
581 
outgrowth  of,  572 
predisposition  to,  570 
secondan,',  578 
etiology  of,  570 
gait  in,  579 
pathology  of,  581 
time  of  onset  of,  570 
treatment  of,  583 
by  braces,  585 

duration  of,  587 
exercise  in,  583 
expectant,  385 
Lorenz's,  589 
manipulation  in,  583 
operative,  587 

osteoclasis  in,  589 
osteotomy  in,  587 
cuneiform,  589 
plaster  bandage  in,  587 
posture  in,  583 
Thomas  brace  in,  585 
Wolff's,  589 
unilateral,  580 
Koenig's  statistics  of  abscess  in  tuber- 
culous   disease    of    knee-joint, 
426 
of  non-tuberculous  affections  of 

hip-joint,  398 
of  tuberculous  disease  of  hip-joint, 
310 
Kyphosis,  224 

of  adolescents,  140,  226 
postural,  225 
in  rhachitis,  500 
treatment  of,  226 


Late  rickets,  504 

Lateral  curvature  of  spine,  149 

changes  in  anteroposterior  con- 
tour in,  155 
compensatory  deformity  in.  162 
congenital,  167 
diagnosis  of,  174 
postvire  in,  174 
mobility  in,  175 
due  to  occupation,  167 
etiology  of.  161 
hereditary  influence  in,  160 
high  hip  in,  156 


856 


INDEX 


Lateral  curvature  of  spine,  high  shoul- 
der in. 156 
incidental,  166 
lateral  deviation  in,  151 
occupation  as  inducing  defonn- 
ity,  170 
statistics  of,  170 
pathology  of,  157 
prevention    of    deformitv  ,  in 

179      ■ 
records  of,  175 
relative  frequency  of,  161 
statistics  of,  161 
as  to  age,  162 
as  to  sex,  162 
rhachitic.  16S 

statistics  of,  168,  169 
rotation  in,  151 

secondary-   to    defonnity   else- 
where, 165 
to    disease    within    thoracic 

walls,  165 
to  paralysis,  165 
sjnnptoms  of,  173 
treatment  of,  179 
braces  in,  use  of,  216 
duration  of,  222 
exercises  in,  184-200 
general,  185-200 
muscle  building,  207 
self-correcting,  201 
Teschner's,  185 
forcible  correction  of  deform- 
ity in,  218 
combined   with   fixa- 
tion, 219 
genera),  221 
high  shoe  in,  221 
posture  in,  184 

and  support  during  recmn- 
bency  in,  221 
removal  of   superincumbent 
weight,  214 
by  self-suspension,  214 
Volkmann  seat  in,  221 
varieties  of  deformity  in,  172 
statistics  of,  172 
Leg,  muscular  cra,mp  of,  434 
Leverage,  reverse,  forcible  correction 
by,  in  treatment  of  tuljerculous  dis- 
ease of  knee-joint,  418 
Ligaments,  spinal,  rupture  of,  129 
Ligamentum   patella;,   elongation   of, 
447 
etiology  of,  447 
symptoms  of,  447 
treatment  of,  447 
Limb,  actual  lengthening  of,  in  tuber- 
culous   disease    of    hip- 
joint,  318 
oi  l<nee-joint,  414 
of  liip-joint,  316 
shortening  of,  in  tuberculous  dis 
ease  of  knee-joint,  414 


Limb,    apparent    lengthening    of,    in 
tuberculous     disease    of    hip- 
joint,  307 
shortening  of,  in  tuberculous  dis- 
ease of  hip-joint,  310 
distortion  of,  in  tuberculous  disease 
of  liip-joint,  307 
of  knee-joint,  411,  412 
method  of  estimating  degree  of  dis- 
tortion of,  in  tuberculous  disease 
of  hip-joint,  322 
Limp,  intermittent,  735 

as  sjinptom  of  tuberculous  disease 
of  hip-joint,  304 
Linear  osteotomy  in  treatment  of  coxa 

vara,  560 
Lipoma  arborescens,  tuberculous  joint 

disease  in,  255 
Localized  osteomyelitis,  279 
Loose  bodies  in  kiiee-joint,  634 
Lordosis,  228 

treatment  of,  229 

in  tuberculous  disease  of  spine  in 
lower  region,  39 
Lorenz  operation  in  treatment  of  con- 
genital dislocation  at  hip-joint, 
527 
treatment  of  knock-knee,  589 
Lovett's  table  for  estimating  degree  of 
distortion   of   limb   in   tuberculous 
disease  of  hip-joint,  323 


M 


Malleotom  Y  in  treatment  of  neglected 

talipes,  789 
Mallet  finger,  496 

Manipulation  in  treatment  of  acquired 
talipes  equinus,  818 
of  torticollis,  654 
Manual  correction,  forcible,  in  treat- 
ment    of    neglected     talipes, 
782 
in   treatment  of    infantile    club- 
foot, 779 
Measurements  in  tuberculous  disease 

of  hip-joint,  321 
Mechanical     treatment     of     infantile 

talipes,  769 
Melos-extremity,  134 
Metatarsal  arch,  anterior,  723 
weakness  of,  721 
bones,  fracture  of,  746 
Metatarsalgia,  anterior,  721 
etiology  of,  722,  726 
influence  of  shoe  in  causing  pain 

in,  725 
pathology  of,  722 
treatment  of,  727 
operative,  729 
Metatarsus  varus,  740 
Mollitis  ossium,  508 
Morbus  coxae,  298 


INDEX 


857 


Mortality  in   tuberculous  disease  of 

hip-joint,  391 
Morton's  neuralgia,  721.     See  Meta- 

tarsalgia,  anterior. 
Muscles,  pectoral,  defective  formation 

of,  232 
Muscular  atrophy,  progressive,  633 
myelopathic  fonn  of,  633 
myopathic  form  of,  634 
deformity  in  Pott's  disease,  28 
dystrophy,  634 

paralysis,  pseudohypertrophic,  634, 
635 
diagnosis  of,  635 
treatment  of,  600 
Myelopathic  paralysis,  633 
atrophy,  633 


N 


Nerve  grafting  in  treatment  of  acute 

anterior  poliomyelitis,  620 
Nervous  system,  diseases  of,  598 
Neuralgia,  Morton's,  721.     See  Meta- 
tarsalgia,  anterior, 
plantar,  734 

treatment  of,  734 
Neuritis,  636 

localized,  663 
Neurotic  joints,  639 
spine,  143 

sj-inptoms  of,  143 
treatment  of,  144 
"Night  cry"  in  Pott's  disease,  28 

as  symptom  of  tuberculous  dis- 
ease of  hip-joint,  304 
Non-defonning   club-foot,    716.     See 

Contracted  foot. 
Non-tuberculous   affections  of   knee- 
joint,  434 
of  spine,  126 
deformities  of  knee-joint,  434 
diseases  of  joints,  266 


Obstetrical  injury  to  brachial  plexus, 
repair  of,  487 
paralysis  of  ann,  482 
Occupation  causing  lateral  curvature 
of  spine,  167 
induchig  defomiity  in  lateral  curva- 
ture of  spine,  170 
Ocular  torticollis,  663 
(Edema  of  feet,  congenital,  812 
Operations  for  relief  of  final  defomiity 
in  tuberculous  disease  of  hip-joint, 
430 
Opisthotonos,  cervical,  663 
Osteitis  deformans,  140,  510 

local,  511 
Osteoarthritis,  279 


Osteoarthritis,  etiology  of,  282 
Heberden's  nodosities  in,  283 
of  hip-joint,  403 
symptoms  of,  404 
treatment  of,  404 
pathology  of,  280 
symptoms  of,  282 
treatment  of,  284 
Osteoarthropathy,  hypertrophic,  sec- 
ondary, 512 
Ostechondritis,  syphilitic,  266 
Osteoclasis   in    treatment  of   knock- 
knee,  589 
Osteoclasts  in  treatment  of  neglected 

taUpes,  794,  796 
Osteomalacia,  508 
in  cliildhood,  509 
local,  510 
treatment  of,  509 
Osteomyelitis,  acute,  277 
infectious,  277 
locahzed,  279 
of  spme,  acute,  127 
infectious,  127 
Osteoperiostitis,  syphilitic,  206 
Osteopsathyrosis,  idiopathic,  507 
Osteotomy  in  congenital  dislocation  at 
hip-joint,  543 
cuneiform    in    treatment    of    coxa 
vara,  560 
of  neglected^talipes,  800 
linear,   in  treatment  of  coxa  vara, 

560 
secondary  in  treatment  of  neglected 

talipes,  802 
in  treatment  of  acute  anterior  polio- 
myelitis, 620 
of  knock-knee,  587 
Overcorrection,  forcible,  in  treatment 

of  rigid  weak  foot,  707 
Overlapping  toes,  745 


Facet's  disease,  140 
Painful  great  toe,  735 

toe-joint  in  older  subjects,  737 
heel,  733 
Painless  synovitis  of  knee,  438 
Palhativc  treatment  of  congenital  dis- 
location at  hip-joint,  549 
Paralysis  in  acute  anterior  poliomve- 
litis,  600 
of  ann,  obstetrical,  482 

treatment  of,  483 
cerebral,  of  childhood,  623 
acquired,  623,  627 
after-birth,  624 
deformities  in,  628 
disability  in,  628 
loss  of  growth  in,  628 
congenital,  623 
paralj'sis  in,  626 


858 


INDEX 


Paralvsiij.  cerebral,  of  childhood,  con- 
genital, weakness  in,  626 
defonnities  in,  627 
distribution  of,  623 
statistics  of,  623 
etiology  of,  623 
of  intrauterine  origin,  624 
occurring  during  labor,  624 
pathology  of,  623 
prognosis  in,  632 
symptoms  of,  general,  625 
mental,  626 
motor,  625 
treatment  of,  629 
of  hemiplegia,  629 
of  paraplegia,  631 
transplantation    of  tendons, 
630,  632 
infantile,  598.     See  Acute  anterior 

poliomyelitis, 
muscular,  pseudohypertrophic,  634, 

635 
myelopathic,  633 
in  Pott's  disease,  29 
spastic,  623 
spinal,  spastic,  633 
Paralytic  lorticollis,  663 
Paraplegia,  Pott's,  115 
Partial  separation  of  epiphysis  of  head 

of  femur  in  adolescence,  565 
Patella,  absent,  443,  444 

displacement  of,  acquired,  444 

congenital,  444 
rudimentary,  443,  444 

treatment  of,  444 
slipping,  444 
etiology  of,  445 
symptoms  of,  445 
treatment  of,  446 
operatiye,  446 
Pectus  carinatmn,  233 

excayatum,  235 
Pelyic  joints,  relaxation  of,  142 
Peh'is,  inclination  of,  35 
Periarthritis  scapulohumeral,  478 
of  shoulder,  478 
symptoms  of,  478 
treatment  of,  479 
Peronei  tendons,  displacement  of,  746 
Persistent  abduction    in    weak    foot, 

692 
I'es  planus,  692 

Phahiiiges,     displacements     of,     con- 
genital, 495 
Plir'lps'    operatif)n    in    treatment    of 

neglected  talipes,  797 
Pigeon  breast  in  rliachitis,  500 
chest,  233 

in  tuberculous  disease  of  spine  in 
thoracic  region,  52 
toe,  739 
Plantalgia,  734 
•Plantar  neuralgia,  734 
treatment  of,  734 


Plaster  bandage  in  treatment  of  in- 
fantile club-foot,  769 
of  knock-knee,  587 
of  tuberculous  disease  of  knee- 
joint,  417 
strapping  in  treatment  of  rigid  weak 
foot,  713 
Poliomyelitis,  anterior,  acute,  598 
age  of  onset  in,  599 
statistics  of,  599 
deformity  in,  604 
causes  of,  604 
functional  use  as  cause  of, 

606 
grayity,  605 
habitual  posture,  605 
muscular  action,  605 
deformities  of  neck  in,  607 
reduction  of,  616 
secondary,  608,  609 
subluxation,  606 
of  trunk  in,  607 
of      upper      extremity     in, 
607 
diagnosis  of,  601 

from   diphtheritic   paralysis, 

603 
from  joint  disease,  602 
from  multiple  neuritis,  602 
from    obstetrical    paralysis, 

603 
from  other  forms  of  spinal 

paralysis,  602 
from    paralysis    of    cerebral 

origin  in  childhood,  602 
from  Pott's  paraplegia,  602 
from  pseudoparalysis,  603 
from  rheumatism,  602 
from    spastic    spinal    para- 
plegia, 602 
etiology  of,  599 

paralysis  of  different   muscles 
in,   effects   of,  upon  func- 
ti>  n,  604 
distribution  of,  600 
pathology  of,  598 
prognosis  in,  603 

electrical  test  in,  (i03 
retardation  of  growth  in,    60S, 

609 
symptoms  of,  600 
treatment  of,  610 

mechanical,     principles     of, 

610 
operative,  616 

arthrodesis  in,  620 
Hoffa's,    for    paralysis    of 

deltoid  muscle,  618 
nerve  grafting  in,  620 
osteotomy  in,  620 
reduction  of  deformity  in, 

tendon  transplantation  in, 
618 


INDEX 


859 


Polioiiiyeliti.s,   anlnrior,   acute,    treat- 
ment     of,       operative, 
transplantation  tor  par- 
alysis  of  anterior  mus- 
cles of  hig,  (HO 
of  arm,  (516 
of  muscles  of  hip,  ()14 
of  posterior  muscles     of 

leg,  611 
of  thigh  muscles,  612 
of  paralytic  scoliosis,  616 
Popliteal  region,  hursre  and  cysts  in, 

440 
Postural  kyphosis,  225 
Posture  in  treatment  of  knock-knee. 

Potbelly  in  rhachitis,  500 
Pott's   disease,  17.     See  Tuberculous 
disease  of  spine, 
lumbar,  in  infancy,  peculiarities 
of,  .50 
paraplegia,  115 
Prepatellar  liursitis,  439 
Pretil)ial   f)\irsa,    superficial,    enlarge- 
ment of,  440 
bursitis,  439 

symptoms  of,  439 
treatment  of,  440 
Progressive  muscular  atrophy,  633 
myelopathic  fonn  of,  633 
myopathic  form  of,  634 
Pseudohvpertrophic    muscular    para- 
lysis, 634,  635 
Pseudoparalysis  in  rhachitis,  502 
Psoas  contraction  in  tuberculous  dis- 
ease of  spine  in  lower  region,  40 
Psychical  torticollis,  664 
Puerperal  arthritis,  272 


Q 

Quiet  effusion  at  knee,  438 


Recurrent  dislocation  of   shoulder, 
487 
treatment  of,  487 
synovitis  of  knee,  435 
Kelaxation  of  pelvic  joints,  142 
Hc^ardation  of  growth  in   acute  ante- 
rior poHomyelilis,  (i08,  (i09 
Retention   brace  in   treatment  of  in- 
fantile club-foot,  777 
Retrocalcaneobvn'sitis,  730.  5ceAchil- 

lol)ursitis. 
Rhachitie  attitude,  131,  .502 

distortions  of  lower  linil)s,  general, 

.597 
rosary,  500 
spine,  130 

natural  cure  oi>  131 


Rhachitie  spine,  treatment  of,   131 

torticollis,  663 
Rhachitis,  498 

age  of  onset  of,  498 

att  ilud(!  in,  502 

caput  quaciratuni  in,  .")00 

cranif)tal)es  in,  500 

cubitus  valgus  in,  .501 
varus  in,  501 

defonnities  in,  .500 
prevention  of,  504 

double  joints  in,  .500 

otiologv  of,  498 

fcctal,  505 

Harrison's  groo\'e  in,  500 

kyphosis  in,  500 

pathology  of,  499 

pigeon  l)reast  in,  500 

potbelly  in,  .500 

prognosis  of,  502 

pseudoparalysis  in,  502 

rhachitie  rosary  in,  500 

.scoliosis  in,  .500 

symptoms  of,  499 

treatment  of,  503 
Rheumatism,  289 

of  ankle-joint,  465 

gonorrha'al,  270.     Sec  GonorrlKral 
arthritis 

of  spine,  1.33.     Sec  Spondylitis  de- 
forma!is. 
Rheumatoid  arthritis,  284 
in  childhood,  287 
etiologv  of,  287 
treatment  of,  287 
Ribs,  absence  of,  231 

cervical,  231 
Rice  bodies  in  tuberculous   joint  dis- 
ease, 256 
Rickets,  489.     See  Rhachitis. 

late,  504 

scurvy,  .506 
Rigid  weak  foot,  706 

treatment  of,  706 
Rotary   lateral    cur\ature    of    spine, 

149' 
Rotation  in  lateral  cur\ature  of  spine, 

151 
Round  back.  223 
hollow,  223.  224 

shoulders,  225 
Rudimentary  patella,  443,  444 


Sacroiliac  articulation,  injury  of,  118 
disease,  146 

diagnosis  of,  146 
prognosis  in,  146 
.s\nnptoms  of,  146 
treatment  of,  147 
Sarcoma  of  femur,  403 
of  spine    126 


860 


INDEX 


Scapula,  congenital  elevation  of,  229 
etiolog\-  of,  230 
treatment  of,  231 
Scapular  crepitus,  236 
Scapulohumeral  periarthritis,  478 
Sciatic  scohosis,  145 
Sciatica,  deformity  secondary  to,  145 
ScoHosis,  149.     See  Lateral  curvature 
of  spine, 
hysterical,  638  , 
in  rhachitis,  500 
Scorbutus,  290 
infantile,  506 

patholog}-  of,  507 
SATQptoms  of,  507 
treatment  of,  507 
Scur\y,  290,  506 

rickets,  506 
Secondary-    deformities    in    neglected 
tahpes,   789 
hypertrophic  osteoarthropathy,  512 
Septic  infection  in  tuberculous  disease 

of  bones  and  jomts,  257 
Shaffer  extension  shoe  in  treatment  of 

acquired  tahpes  equinus,  818 
Shoes,  747 

in  treatment  of  weak  foot,  698 
Shoulder,    congenital    dislocation    of, 
482 
dislocation  of,  congenital,  reduction 
of  deformity  in,  484 
recurrent,  487 
treatment  of,  487 
operative,  488 
Shoulder-joint,    bursitis   at,    chronic, 
479 
tuberculous  disease  of,  466 
age  at  incipiency  of,  467 

statistics  of,  467 
pathology  of,  466 
prognosis  in,  469 
symptoms  of,  467 
treatment  of,  469 
operative,  469 
periarthritis  of,  478 
symptoms  of,  478 
treatment  of,  479 
Signs,  local,  of  tuberculous  disease  of 

hip-joint,  325 
Sinuses  in  tuberculous  disease  of  hip, 

treatment  of,  382 
Skin,    hypersesthesia  of,    in   neurotic 

spine,  143 
Slipping  patella,  444 
etiology  of,  445 
symptoms  of,  445 
treatment  of,  446 
operative,  446 
Snapping  finger,  495 
hip,  549 
knee,  447 

treatment  of,  448 
Socks,  751 
Spasmodic  torticollis,  659 


Spastic  paralysis,  623 
spinal  paralysis,  633 
Spina  bifida  and  talipes,  812 

ventosa,  476 
Spinal  cord,  length  of,  35 
hgaments,  rupture  of,  129 
paralysis,  spastic,  633 
Spme,  actinomycosis  of,  128 

anteroposterior  deformities  of,  224 
k^'phosis,  224 
lordosis,  228 

treatment  of,  229 
arthritis  of,  infectious,  133 
suboccipital  region  of,  133 
treatment  of,  133 
carcinoma  of,  126 
changes  in   contour   of,    in   Pott's 

disease,  28 
deformity  of,  tabetic,  140 
divisions  of,  32 
fracture  of,  129 

"gonorrhoeal  rheumatism  of,"  133 
hysterical,  144 
symptoms  of,  145 
treatment  of,  145 
infectious  arthritis,  133 

disease  of  coverings  or  articula- 
tions of,  132 
injury  of,  128 
landmarks  in  diagnosis  of  disease 

of,   34 
lateral  curvature  of,  149 

changes  in  anteroposterior  con- 
tour in,  155 
compensatory  deformity  in,  165 
congenital,  167 
deviation  in,  151 
diagnosis  of,  174 
mobility  in,  175 
posture  in,  174 
due  to  occupation,  167 
etiology  of,  161 
hereditary  influence  in,  169 
high  hip  in,  156 

shoulder  in,  156 
incidental,  166 

occupation    as    inducing    de- 
formity, 170 
statistics  of,  170 
pathology  of,  157 
prevention  of  deformity  in,  179 
records  of,  175 
relative  frequency  of,  161 
statistics  of,  161 
as  to  age,  162 
as  to  sex,  162 
rhachitic,  168 

statistics  of,  168,  169 
rotation  in,  151 

secondary   to   deformity   else- 
where, 165 
to    disease    within    thoracic 

walls,  165 
to  paralysis,  165 


INDEX 


861 


Spine,  lateral  curvature  of,  symptoms 
of,  173 
treatment  of,  179 

braces  in,  use  of,  216 
duration  of,  222 
exercises  in,  184-200 
general,  185-200 
muscle  building,  207 
self-correcting,  201 
Teschner's,  185 
forcible     correction    of    de- 
formity in,  218 
combined    with    fixa- 
tion, 219 
general,  21 
high  shoe  in,  221 
posture  in,  184 

and  support  during  recum- 
bency in,  221 
removal  of  superincumbent 
weight  in,  214 
by  self-suspension,  214 
Volkmann  seat  in,  212 
varieties  of  deformity  in,  172 
statistics  of,  172 
ligaments  of,  rupture  of,  129 
malignant  disease  of,  126 

diagnosis  of,  127 
neurotic,  143 

hypersesthesia  of  skin  in,  143 
symptoms  of,  143 
treatment  of,  144 
non-tuberculous  affections  of,  126 
normal,  contour  and  flexibility  of,  30 

variations  in,  32 
osteoarthritis  of,  133.    See  Spondy- 
litis deformans, 
osteomyelitis  of,  acute,  127 
symptoms  of,  127 
treatment  of,  128 
rhachitic,  130 
diagnosis  of,  from  Pott's  disease, 

50 
natural  cure  of,  131 
treatment  of,  131 
rheumatism  of,   133.     Sec  Spondy- 
litis deformans, 
rheumatoid  arthritis  of,  134 
sarcoma  of,  120 
syphilis  of,  126 

diagnosis  of,  126 
tabetic  deformity  of,  140 
tuberculous  disease  of,  17 
complications  of,  108 
abscess,  108 

course  and  peculiarities  of, 

110 
in  different  regions,  110 
statistics  of.  lOS 
treatment  of,  112 
aspiration  in,  114 
injections  in,  114 
correction     of    defonnity     in, 
Calot's  operation  in,  123 


Spine,  tuberculous  disease  of,  correc- 
tion   of,   deformity    in, 
forcible,  123 
Goldthwait's  apparatus  in, 

91 
Metzger-Goldthwait's   ap- 
paratus in,  93 
diagnosis  of,  61-65 

Roentgen  rays  in,  65 
history  in,  36 
later  effects  of   deform  it}-   in, 

125 
in  lower  region,  39,  00 
attitude  in,  39 

diagnosis  of,  from  bilateral 
congenital  dislocation  of 
hip,  48 
differential,  46 
from    hip   disease    in    in- 
fancy, 48 
from  lumbago,  46 
from     muscular     dystro- 
phies, 48 
from  sacroiliac  disease,  47 
from  sciatica,  46 
from    secondary    hip    dis- 
ease,  49 
from  spondjdolisthesis,  47 
from  strain  in  back,  46 
gait  in,  39 

location  of  pain  in,  41 
lordosis  in,  39,  40 
pelvic  abscess  in,  45 

diagnosis    of,    differen- 
tial, 49 
psoas  contraction  in,  40 
paralysis  in,  115 
duration  of,  117 
frequency  of,  116 
liability      to,      in     different 

regions,  116 
local,  123 
prognosis  of,  120 
.symptoms  of,  118 
time  of  onset,  117 
treatment  of,  120 
laminectomy  in,  122 
operative,  121 
physical  signs  of,  37 
rational  signs  of,  35 
record  of  the  case  in,  66 
recurrence  of,  125 
secondary  defonnities  of,  125 
in  thoracic  region,  52 
abscess  in,  55 
attitudes  in,  52 
deviation  of  .spine  in,  54 
diagnosis  of,  55 

differential,  56 
muscular  spasm  in,  54 
]iain  in,  53 
pigeon  chest  in,  52 
respiration  in,  54 
treatment  of,  67 


862 


INDEX 


Spine,  tuberculous  disease  of,  treat- 
ment of,  duration  of,  123 
indications    for,    bv    recum- 
bency, 100 
special,     of     diiferent    re- 
gions, 101 
lower  dorsal  region, 
105 
region,  102 
middle  cervical  re- 
gion, 10(5 
dorsal  region,  106 
occipitoaxoid       re- 
gion, 107 
upper     dorsal     re- 
gion, 106 
mechanical  ambulatory  sup- 
ports in,  76 
back  brace,  76 
comparison  of,  96 
corset,  Phelps,  98 
plaster,  95 
Weigel's,  98 
corsets,  95,  97 
plaster  corset,  95 
jacket,  82 

application  of,  in 
recumbency,91 
modifications  of, 
97 
Taylor   brace   in,   76, 
79 
head  support,  82 
Bradford  frame  in,  69 

modifications  of,  69,  70 
general  principles  of,  67 
horizontal  fixations  in,  68 
Lorenz  apparatus  in,  68 
Phelps'  bed  in,  68 
principles  of,  in  their  prac- 
tical application,  98 
wire  cuirasse  in,  69 
in  upper  region,  58 
abscess  in,  59 
attitude  in,  58 
symptoms  of,  58 
typhoid,  132 

diagnosis  of,  132 
trf-atirifnt  of,  132 
variations  in  contour  of,  223 
Splint,  Billroth,  in  tn-atnient  of  tuljer- 
culoiis  disease  of  knee-joint,  419 
in  treatment  of  infantile  eliib-ioot, 
773 
SiKiiidylitis  defonnans,  I'.VA 
cases  of,  137 
pathology  of,  133 
symptoms  of,  13(i 
synonyms  of,  133 
trfiatment  of,  1 38 
varieties  of,  1 34 
superficialis,  18 
traumatic,  129 
treaiiiieiit  of,  129 


SpondyloUsthesis,  140 

Spondylose    rhizomelique,     134.     See 

Spondyhtis  deformans. 
Spontaneous  dislocation  of  hip-joint, 
400 
subluxation  of  wrist,  490 
Sprain  of  ankle,  459 
chronic,  462 

treatment  of,  462 
symptoms  of,  459 
treatment  of,  459 
strapping  in,  460 
of  wrist,  480 
chronic,  480 
Sprengel's  deformity,  229 
etiology  of,  230 
treatment  of,  231 
Sternomastoid  muscle,  hsematoma  of, 

646 
Stiffness  as  symptom  of  tuberculous 

disease  of  hip-joint,  305 
Strains  of  knee  in  childhood,  434 

of  tendo  Achillis,  733 
Strapping  in  treatment  of  sprain  of 

ankle,  460 
Subacute  arthritis,  of  hip-joint,  400 
Subastragaloid  disease,  453 
Subluxation  of  clavicle,  236 
treatment  of,  236 
of  hip,  congenital,  549 
of  wrist,  490 
etiology  of,  491 
spontaneous,  490 
treatment  of,  491 
Support  in  treatment  of  weak  foot, 

700 
Supracotvloid     dislocation     at     hip- 
joint,  524 
Swelling  about  ankles,  465 
Sjmovial  tuberculosis,  arborescent,255 
of  knee-joint,  427 
treatment  of,  427 
Synovitis  of  knee,  acute,  434 
chronic,  435 
incidental,  438 
painless,  438 
recurrent,  435 
Syphilis  of  spine,  126 
diagnosis  of,  126 
Syphilitic  diseases  of  joints,  266 
osteochondritis,  266 
osteoperiostitis,  266 
pain  and  swelling  of  joints,  267 


TATiETif  (Icrormitv  of  spine,  110 
'i'alipes,  752 

Mc<iuired,  638,  755,  813 

(leformity    in,     dcxciopineiit    of, 

814 
diagnosis    of,    differential,    Irnin 
eongeuita]  talipes,  815 


INDEX 


863 


Talipes,  acquired,  etiology  of,  813 
arcuatus,    716.       See      Contracted 

foot, 
calcaneovalgus,  754 
acquired,  830 

treatment  of,  830 
congenital,  808 
calcaneovaru.s,  754 

congenital,  808 
calcaneus,  753 
acquired,  822 

deformity  in,  development  of, 

823 
symptoms  of,  823 
treatment  of,  824 
Judson  brace  in,  824 
operative,  825 

Whitman's    operation    in, 

828 
Willett's  operation  in,  826 
congenital,  807 
cavus,  716.     See  Contracted  foot. 
congenital,  638,  755 
anatomy  of,  762 
etiology  of,  756 
other  varieties  of,  806 
equinocavus,  congenital,  808 
equinovalgus,  754 

associated    with    congenital    ab- 
sence of  fibula,  809 
etiology  of,  810 
statistics  of,  809 
treatment  of,  810 
congenital,  808 
equinovarus,  754 
anatomy  of,  762 

associated    with    congenital    ab- 
sence of  tibia,  811 
prognosis  of,  811 
statistics  of,  811 
infantile,   treatment   of,   767 
symptoms  of,  766 
treatment  of,  767 
equinus,  753 
acquired,  815 
etiology  of,  816 
symptoms  of,  817 
treatment  818 

arthrodesis  in,  821 
inmii'diate  correction  of  de- 
formity in,  818 
Thomas'    wrench    in, 

819 
tonic  effect  of,  820 
manipulation  in,  SIS 
Shaffer    extension    shoe    in, 
SIS 
congenital,  S()7 
iiifanlile,  treatment  of,  767 
first  stage  of,  768 
Judson's  brace  in,  773 
manual  correction  in,  779 
mechanical,  7()9 
plaster  l)andage,  in  769 


Talipes,  infantile,  treatment  of,  pre- 
liminary    manipulation    in, 
769 
principles  of,  768 
rectification   of  deformitj'     in, 

768 
retention  brace  in,  777 
second  stage  of,  776 
splints  and  braces  in,  773 
support    in    second    stage    of, 

776 
Taylor  brace  in,  777 
tenotomy  in,  775 
neglected,  secondary  deformities  in, 
789 
treatment  of,  780 
age  influencing,  781 
division   of   tendo   Achillis   in, 

791 
forcible  manual  correction  in, 

782 
importance   of   functional   use 

in,  787 
malleotomy  in,  789 
by    method    of    Julius  Wolff, 

793 
open    incision   combined    with 
forcil)le  rectification  of  de- 
formity in,  797 
method  of,  792 
operations  on  astragalectoiliv, 
800 
bones  in,  800 

cuneifonn  osteotomy  in,  800 
secondary  osteotomy,  802 
by  osteoclasts,  794,  796 
Phelps'  operation  in,  797 
rapid   correction  of  deformity 

in.  781 
simple  mechanical  rectification 
of  det'ormitv  in  walking  eliiltl- 
ren,  802 
subcutaneous  tenotomy  in,  790 
Thomas'  method  in,  795 
by  wrenches,  794 
paralytic,  arthrodesis  in,  841 
tendon  splicing  in,  841 

transplantation  in  eombination 
with  other  i)roe(Hlurcs,  S40 
for  relief  of,  833 
the  operation,  837 

modifications  of,  S3S 
selection    of    muscles    for, 

834 
time  for  operation  of,  834 
plantaris,  716.     ^V'r  Contracted  foot. 
s))ina  l)iti(la  and,  S12 
statistics  of,  760 

relative    frefiuency    of    ditT(  rent 
forms  of,  742 
valgocavus,  congenital.  SOS 
valgus,  753 

congenital,  S()7 
varieties  of,  753 


864 


INDEX 


Talipes  varus,  753 

associated    with    congenital 

absence  of  tibia,  811 
congenital,  S06 
Tarsus,  tuberculous  disease  of,  458 

distribution   of,   to   tndiAddual 

bones,  458 
statistics  of,  458 
treatment  of,  459 
Taylor  brace  in  treatment  of  infantile 

club-foot,  777 
Tendo  Achlllis,  division  of,  in  treat- 
ment of  neglected  talipes,  791 
strain  of,  733 
Tendon  transplantation  in  treatment 

of  paralytic  defomiities,  618 
Tenosvnovitis  at  ankle-joint,  463 
treatment  of,  463 
tuberculous,  464 
at  A\Tist -joint,  acute,  480 
Tenotomy,    subcutaneous,    in    treat- 
ment   of    neglected    talipes, 
790 
of  torticollis,  654 
in  treatment  of  infantile  club-foot, 
775 
Thomas  brace  in  treatment  of  knock- 
knee,  585 
knee  brace  in  treatment  of  tuber- 
culous disease  of  knee-joint,  420 
method  in  treatment  of  neglected 

talipes,  795 
treatment  of  rigid  weak  foot,  713 
wrench   in   treatment   of   acquired 
tahpes  equinus,  819 
Tibia,  anterior  curvature  of,  595 

displacement  of,  442.     See  Genu 
recurvatum,  congenital. 
Tibial  tubercle,  injury  of,  440 
Toe,  hammer,  744 

-joint,  painful  great,  737 
overlapping,  745 
painful,  great,  735 
pigeon,  739 
Torticollis,  642 
acquired,  642,  648 

table  of  exciting  causes  of,  650 
varieties  of,  648 
acute,  648 

etiology  of,  648 
spastic,  649 
symptoms  of,  650 
treatment  of,  657 
chronic,  treatuK^nt  of,  654 
by  manipulation,  654 
congenital,  642,  (i43 
etiology  of,  645 
pathology  of,  647 
treatment  of,  654 

by  manipulation,  654 
by  open  metliod,  655 
ov(;rcorrection  of  deformity  in, 

655 
by  subcutaneous  tenotomy,  654 


Torticollis,  diagnosis  of,  651 
from  arthritis,  653 
from  Pott's  disease,  651 
following  diphtheritic  paralysis,  663 
irregular  forms  of,  648,  663 
ocular,  663 
paralytic,  663 
psycliical,  664 
rhacliitic,  663 
spasmodic,  648 
etiology  of,  659 
pathology  of,  659 
prognosis  in,  659 
treatment  of,  659 

description    of    operation    in, 

660 
operative,  659 
treatment  of,  653 

by  manipiilation,  654 
Traction  in  treatment  of  tuberculous 

disease  of  knee-joint,  418 
Transplantation  of  Sartorius  muscle, 

619 
Traumatic  coxa  vara,  562 

separation  of  epiphysis  of  head  of 

femur,  564 
spondylitis,  129 
Traumatisms  at  hip- joint,  398 
Treatment  of  abscess  in  tuberculous 
disease  of  hip,  380 
of  knee-joint,  426 
accessory,  of  tuberculous  disease  of 

knee-joint,  424 
of  achillobursitis,  731 

operative,  732 
of  acquired  genu  recurvatum,  442 
talipes  calcaneovalgus,  830 
calcaneovarus,  830 
calcaneus,  824 
equinovalgus,  832 
equino varus,  831 
equinus,  818 
of  acute  anterior  poliomyelitis,  610 
mechanical  principles  of,  610 
operative,  616 
epiphysitis  at  hip-joint,  399_ 
infectious  arthritis  of  hip-joint, 

399 
osteomyelitis  of  spine,  128 
torticollis,  657 
of  anchylosis,  293 

forcible  correction  in,  295 
operative  exploration  in,  296 
passive  motion  in,  294 
of  anterior  Ijow-leg,  597 

metatarsalgia,  727 
of  arthritis  complicating  infectious 
diseases,  273 
deformans,  404 

of  suboccipital  region  of  spine, 
133 
Bier's,    of   tuberculous   disease    of 

knee-joint,  425 
of  bilateral  hip  disease,  376 


INDEX 


865 


Treatment  of  how-leg,  592 
by  hvacffH,  592 
expectant,  592 
operative,  594 
of  bursitis,  403 
of  calcaneobursitis,  731 
of  cerebral  paralysis  of  childliood, 

629 
of  Charcot's  disease,  292 
of  chondrodystrophia,  50G 
of  chronic  sprain  of  ankle,  462 
of  club-hand.  493 

of  congenital  contraction  of  fingers, 
494 
at  knee,  448 
dislocation  at  hip-joint,  526 
elevation  of  scapula,  231 
genu  recurw'ituni,  443 
torticollis,  654 
of  contracted  foot,  719 

operati\-e,  720 
of  coxa  ^'ara,  558 

operative,  560 
of  displacement  of  peronei  tendons, 

746 
of  DupuA'tren's  contraction,  497 
during   convalescence   from   tuber- 
culous disease  of  knee-joint,  425 
of  elongation  of  ligamentum  patel- 
la?, 447 
of  extra-articular  disease  of  knee- 
joint,  426 
of  flat  chest,  232 
of  gonorrlicBal  arthritis,  272 
of  hallux  rigidus,  736 
valgus,  741 

operative,  742 
varus,  739 
of  hteniophilia,  290 
of  hanuner-toe,  745 
of  hemiplegia  in  cerebral  parah'sis 

in  childhood,  629 
of  hysterical  joint  affections,  638 

spine,  145 
of  infantile  talipes,  767 
of   internal   derangement   of  knee- 

;oint,  436 
of  jerking  finger,  496 
of  knock-knee,  583 
by  l)races,  585 
expectant,  583 
operative,  587 
of  kyphosis, 226 

of  lateral  curvature  of  spine,  179 
braces  in,  use  of,  216 
duration  of,  222 
exercises  in,  1S4-200 
nniscle  l)uil(Hng.  207 
self-correcting,  201 
Teschner's,  185 
^  forcible     correction     of    de- 
formity in,  218 
combined    with    fixa- 
tion, 219 


Treatment    of    lateral    curvature    ol 
spine,  high  shoe  in,  221 
posture  in,  184 

and    support    during    re- 
cumbency in,  221 
removal  bv  self-suspension, 

214 
of  superincumljent  weight  in, 

214 
'\'olkmann  seat  in,  221 
of  lordosis,  229 

mechanical,  of  tuberculous  disease 
of  hip-joint,  333 
of  knee-joint,  420 
of  neurotic  spine,  144 
of  obstetrical  paralysis  of  ami,  483 
of  osteoarthritis,  284 

of  hip-joint,  404 
of  osteomalacia,  509 
of  pain  in  lower  portion  of  back,  143 
of  painful  heel,  734 
of  paralysis  in  tuberculous  disease 
of  spine,  120 
duration  of,  123 
laminectomy  in,  122 
operative,  121 
of  paralytic  scoliosis,  616 
of  paraplegia  in  cerebral  paralvsis 

of  childhood,  631 
of  periarthritis  of  shoulder,  479 
of  pigeon  chest,  234 
of  plantar  neuralgia,  734 
of  prepatellar  l)ursitis,  439 
of  pretibial  bursitis,  440 
of  recurrent  dislocation  of  shoulde'', 
487 
operative,  488 
of  rhachitic  spine,  131 
of  rhachitis,  503 
of  rheumatoid  arthritis,  287 
of  rudimentary  patella,  444 
of  sacroiliac  disease,  147 
of  scorbutus,  507 
of  sinuses  in  tuberculous  disease  of 

hip,  382 
of  slipping  patella,  446 

operative,  446 
of  snapping  finger,  496 

knee,  448 
of  spasmodic  torticollis,  659 

operative,  660 
of  spondylitis  deformans,  138 
of  sprain  of  ankle,  459 
of  Sprengel's  deformity,  231 
of  suliluxation  of  clavicle,  236 

of  wrist,  491 
of  suppurative  arthritis  in  infancv, 

275 
of   synovial    tuberculosis   of   knee- 

johit,  427 
of  sypliilitic  diseases  of  joints,  269 
of   talipes  equinovalgus  associated 
with  congenital  absence  of  fibula. 
810 


55 


866 


INDEX 


Treatment  of  tenosynovitis  at  ankle- 
joint,  463 
of  torticollis,  653 
of  traumatic  coxa  vara,  563 

spondylitis,  129 
of  travmiatisnis  at  hip-joint,  39S 
of  trigger  finger,  496 
of  tuberculous  disease  of  ankle-joint, 
455 
operative,  456 
of  bones  and  joints,  260 

active  congestion  in,  262 
by  drugs,  261 
local  application  in,  261 
passive  congestion  in,  262 
x-rays  in,  262 
of  elbow-joint,  472 

excision  of  elbow  in,  473 
operative,  473 

reduction    of    deformitj'    in, 
473 
of  liip-joint,  332 
of  knee-joint,  416 
of  shoulder-joint,  469 

operative,  469 
of  spine,  67 

ambulatory  supports  in,  76 
application    of,    in    re- 
cumbency, 91,  94 
comparison  of,  96 
back  brace  in,  76 
corsets  in,  95,  97 
plaster,  95 
Phelps',  98 
Weigel's,  98 
indications  for,     by    recum- 
bency, 100 
special,of  different  regions, 
101 
mechanical,  ambulator}-  sup- 
ports    in,     Taylor 
brace  in,  76,  79 
head  support,  82 
Thomas  collar,  98 
Bradford  frame  in,  09 

modifications  of ,  69,  70 
general  principles  of,  07 
horizontal  fixation  in,  08 
Lorenz's  apparatus  in,  68 
Phelps'  bed  in,  68 
principles  of,  in  their  prac- 
tical application,  98 
wire  cuirasse  in,  69 
plaster  corset,  95 
jacket,  82 

modifications  of,  97 
of  tarsus,  459 
of  wrist-joint,  475 
of  typhoid  spine,  130 
of  weak  foot,  697 
of  wel)bf!d  fingers,  495 
Trigger  finger,  495 
etiology  of,  495 
treatment  of,  496 


Tuberculosis,    syno^•ial,    arborescent, 
255 
of  knee-joint,  427 
treatment  of,  427 
Tuberculous  arthritis,  acute,  276 
disease  of  ankle-joint,  449 
age  at  uicipiency  of,  450 

statistics  of,  450,  451 
astragalonavicular   disease   in, 

453 
defonnity  in,  452 
diagnosis  of,  453 
etiology  of,  450 
pathology  of,  449 
physical  examination  in,  450 
prognosis  in,  457 

statistics  of,  457 
situation  of,  450 

statistics  of,  450 
subastragaloid  disease  in,  454 
symptoms  of,  451 
treatment  of,  455 
operative,  456 

reduction    of    deformitv    in, 
455 
of  bones  and  joints,  246 

arborescent  syno\'iaI,  255 
caries  sicca,  256 
diagnosis  of,  259 
distribution  of  disease  in,  249 
statistics  of,  249 
age,  250 
sex,  250 

side  affected,  250 
etiology  of,  246 
latent  tuberculosis  as  cause 

of,  246 
lipoma  arborescens,  255 
local  predisposition  to,  248 
mode  of  infection  in,  244,  246 
other  forms  of,  254 
patholog}^  of,  251 
perforation  of  joint  in,  251 
predisposition  to,  246 
prognosis  in,  257 
repair  in,  257 
rice  bodies,  256 
septic  infection  in,  257 
treatment  of,  260 

active  congestion  in,  264 
carbolic    acid    locallj*    in, 

262 
b}'  drugs,  261 
iodoform  localty  in,  261 
local  applications  in,  261 
passive  congestion  in,  262 
x-rays  in,  262 
of  elbow-joint,  470 

age  at  incipiency  of,  470 

statistics  of,  470 

pathology  of,  470 

symptoms  of,  471 

treatment  of,  472 

excision  in,  473 


INDEX 


867 


Tuberculous   disease   of    elbow-joint, 
treatment  of,  excision  in, 
statistics  of,  473 
operative,  473 

reduction    of    deformity   in, 
473 
of  hip-joint,  298 
abscess  in,  37S 

significance  of,  379 
treatment  of,  380 

exploratory  operations,382 
actual  lengthening  of  limb  in, 
318 
shortening  of  limb  in,  316 
in  adult,  377 
age  at  incipienc}^,  302 
statistics  of,  302 
amputation  in,  388 
bilateral,  375 

treatment  of,  376 
combined  with  disease  of  other 

parts,  370 
correction     of     deformity     by 

femoral  osteotomy,  390 
defonnities     of     other     parts 

caused  bv,  396 
details  of  1000  cases  of,  330 
diagnosis    of,     from     anterior 
polioinyelitis,  326 
from    congenital   dislocation 

of  hip,  329 
from  coxa  vara,  328 

traumatic,  328 
differential,  326 
from  disease  of  bursse  about 

joint,  328 
from  epiphysitis,  327 
from  extra-articular  disease, 

327 
from    fracture    of    neck    of 

femur  in  cliildhood,  328 
from    gonorrhoeal    arthritis, 

327 
from  growing  pains,  326 
from  hysterical  joint,  329 
from  infectious  arthritis,  327 
from  local  injury,  326 

irritation,  326 
from    osteoarthritis   of   hip, 

327 
from  pelvic  disease,  328 
from  Pott's  disease,  327 
from  rheumatism,  326 
from  sacroiliac  disease,  328 
from  scurvy,  326 
from  sj^novitis,  326 
x-rays  as  means  of,  329 
distortion  of  limb  in,  307 
apparent  lengtlicning,  307 
shortening,  310 
etiology  of.  302 

examination    in,    method    of, 
320 
physical,  320 


Tuberculous  disease  of  hip-joint,  exci- 
sion of  hip  in,  384 
Koenig's  method  of,  384 
history  of  case  of,  320 
in  infancy,  377 
Koenig's  statistics  of,  310 
local  signs  of,  325 
measurements  in,  321 
method  of  estimating  degree  of 
distortion    of    limb 
in,  322 
Kingslev's  table,  325 
Lovett's  table,  323 
of  examination  in,  320 
of  recording  case  of,  329 
fonnuke  used,  330 
mortality  in,  391 

causes  of  death,  392 
natural  cure  in,  310 
pathology  of,  298 
prognosis  of,  391 

as  to  function,  394 
reduction  of  deformity  in  re- 
sistant cases,  388    r  ■ 
relative  frequency  of,  302 
retardation  of  gro\%-th  in,  317 
sex  affected  in,  302 
statistics  of,  302 
side  affected  in,  303 

statistics  of,  303 
sin  vises  in,  382 

treatment  of,  382 
symptoms  of,  303 
atrophy  as,  313 
change  in  contour  of  hip  as, 

313 
distortion  of  liml)'as,'307 
general,  319 
debihtv,  319 
fever,  320 
limp  as,  303,  304 
night  crv  as,  304 
pain  as,"303.  304 
stiffness  as,  305 
treatment  of,  332 

application  of  plaster  spica 

l^andage  in,  350 
during  stage  of  recover}-,  371 
immediate  reduction  of  de- 
formity in,  353 
Lorenz's  spica   bandage  in, 

351 
mechanical,  333 

application    of    traction 

splint  in,  338 
high  shoe  in.  338 
perineal  bands  in,  338 
splinting  in.  334 
stilting  in,  334, 
Taylor's  method   of  trac- 
tion in, 336 
traction  in.  334 
hip  splint  for.  334 
plasters  in,  336 


868 


ISDEX 


Tuberculous     disease     of      hip-joint, 
treatment  of.    mechanical 
traction  in.  straps  for,  336 
by  plaster  bandage,  349 
practical    conibination    of 
traction,     splinting    and 
stilting  in.  361 
reduction    of    deformity    in, 
immediate,  353 
lateral  traction  in,  358 
bv     Thomas'     niethod, 

'346 
by  traction  brace  m,  340 
bv  weights  and  puUevs, 
350 
Marsh's     appliance 
for,  356 
relative  efficiency  of  traction 
hip  splint  in,  341 
antl  splinting  in,  359 
removal  of  direct  pressure  in, 

360 
stilting,  360 
Thomas',  343 
brace  in,  344 

modifications  of,  348 
of  knee-joint,  406 
abscess  in,  426 

Koenig's  statistics  of,  426 
treatment  of,  426 
actual  lengthening  of  limlj  in, 
414 
statistics  of,  414 
shortening  in,  414 
statistics  of,  414 
deformity  in,  432 
diagnosis  of,  415 

from  acute  epiphysitis,  415 
from  Charcot's  disease,  416 
from  ha^marthrosis,  415 
from  hysterical  joint,  416 
from  infectious  arthritis,415 
from  injury  of  knee,  415 
from  osteoarthritis,  416 
from  rheumatism,  416 
from    rheumatoid    arthritis, 

416 
from  sarcoma,  416 
from  synovitis,  415 
distortions  in,  primary,  411 

secondary,  412 
etiology  of,  '409 
extra-articular,  426 

operati\-e     intervention     in, 

420 
treatment  of,  426 
functional  results  of  treatment 

of,  432 
mortahty  in,  431 
causes  of,  431 
influence  of  age  on,  432 

statistics    of,    Koenig's, 
432 
pathology  of,  406 


Tuberculous     disease    of    knee-joint, 
primary  distortions  in,  411 
prognosis  in,  431 
statistics  of,  431 
Gibney's,  431 
secondarv   distortions   in,    412 
statistics  of.  409 

age  at  incipiency.  409 

on  course  and  outcome   of, 

431 
of   results   of   treatnient   of, 
431 
symptoms  of,  409 
synonyms  of,  406 
svnovial  tuberctilosis,  427 

treatment  of,  427 
treatment  of,  416 
accessory,  424 

Bier's  treatment  of,  425 
cauter}^  as,  424 
ichthyol  ointment  as,  424 
iodoform   emulsion   injec- 
tion as,  424 
.r-rays  as,  424 
amputation  in,  430 
arthrectomv  in,  427 
results  of,  428 
statistics  of,  428 
Billroth  splint  in,   419 
excision  in,  428 
results  of,  429 

statistics  of,  429,  430 
forcible    correction    by    re- 
verse leverage  in,  418 
functional  results  of,  432 
mechanical,  420, 
caliper  brace  in,  423 
Thomas  knee  ])race  in,  420 
operations  for  relief  of  final 

deformity  in,  430 
plaster  bandage  in,  417 
reduction    of    deformitv    in, 

417 
statistics  of  results  of,  431 
traction  in,  418 
of  shoulder-joint,  466 
age  at  incipiency  of,  467 

statistics  of,  467 
pathology  of,  466 
prognosis  of,  469 
symptoms  of,  467 
treatment  of,  469 
operati\x',  469 
of  spine,  17 
abscess  in,  29 
age  at  time  of  onset  of,  22 
attitude  in,  cliango  in,  28 
compensatory  deformity  in,  28 
complications  of,  108 
abscess,  108 

course     and     peculiarities 

of,  110 
ii)  different  regions,  110 
statistics  of,  108 


INDEX 


869 


Tubeiculous  disease  of  spine,  compli- 
cations of,    al:)sceF.s 
in,  treatment  of,112 
aspiration  in,  11-4 
injections  in,  114 
contour  of  spine  in,  changes  in, 

28 
correction  of  deformity  in,  123 
Calot's  operation,  123 
of  defomiity  in,  forcible,  123 
Goldtliwait  apparatus  in,  91 
Metzger-Goldthwait    appa- 
ratus in,  93 
deformity  in,  17 
compensatory,  28 
muscular,  28 
diagnosis  of,  in  general,  65 

Roentgen  rays  in,  65 
etiology  of,  22 
historj'  in,  36 

impainnent  of  function  in,  28 
later  effects   of   deformitv  in, 

125 
in  lower  cervical  region,  60 
diagnosis  of,  61 
from  abscess,  64 
from  acute    articular 

rheumatism,  64 
from     cervical     opis-  ! 
thotonos,  63  ■ 

from  injury,  63 
from   rheumatoid  ar- 
thritis, 64 
from  torticollis,  61,  62  i 
region,  39 

attitude  in,  39 

diagnosis  of,    from    bi- 
lateral    congenital 
dislocation  of   hip, 
48 
from    hip   disease    in 

infancy,  48 
from  kuubago,  46 
from  muscular  dystro- 
phies, 48 
from     sacroiliac    dis- 
ease, 47 
from  sciatica,  46 
from     secondary    hip 

disease,  49 
from    spondylolisthe- 
sis, 47 
from   strain  of  iiack. 
46 
gait  in,  39 
in    infancy,    differential 
diagnosis  of,  50 
lateral  inclination  of  bodj^ 

in,  41 
location  of  pain  in,  41 
lordosis  in,  39,  40 
peh'ic  abscess  in,  45 

diagnosis  of,  differen- 
tial, 49 


Tuberculous  disease  of  .spine  in  lower 
region,  pelvic  ab- 
scess in,  diagno- 
sis  of,  from    ap- 
pendicitis, 49 
from  hernia,  50 
from    perinephritic 
aljscess,  49 
psoas  contraction  in,  40 
mortality  in,  25 
muscular  deformity  in,  28 
"night  cry"  in,  28 
pain  in,  27 
paralysis  in,  29,  115 
duration  of,  117 
frequency  of,  116 
hability    to,    in    different 

regions,  116 
local,  123 
prognosis  of,  120 
symptoms  of,  118 
time  of  onset  of,  117 
treatment  of,  120 
laminectomy  in, 122 
operative,  121 
pathology  of,  18 
phj'sical  signs  of,  37 
prognosis  in,  25 
rational  signs  of,  35 
record  of  the  case  in,  66 
recurrence  of,  125 
relative  freqviency  of,  22 

of  dorsal  and  lumbar  in- 
volvement in,  23 
secondary  deformities  of,  125 
sex  in,  23 

situation  of  disease  in,  23 
stiffness  in,  28 
symptoms  of,  26 
~  complicating,  29 
general,  30 
secondary,  29 
in  thoracic  region,  52 
abscess  in,  55 
attitudes  in,  52 
deviation  of  spine  in,  54 
diagnosis  of,  55 

differential,  56 
muscular  spasm  in,  54 
pain  in,  53 
pigeon  chest  in,  52 
respiration  in,  54 
treatment  of,  67 
duration  of,  123 
indications    for,    special,    of 
diff(>rent  regions.  106 
middle    cervical  region, 

106 
occipitoaxoid  region,  107 
upper  dorsal  region,  106 
by  recumliency,  100 
special,  of  different  regions, 
101 
lower  dorsal  region,  105 


870 


I  SB  EX 


Tuberculous  disease  of   spine,  treat- 
ment  of,    indications 
for,  special,  lower  re- 
gion, 102 
middle     dorsal     resion, 
106 
mechanical  ambulatory  sup- 
ports in,   76 
Ijack  brace,  76 
comparison  of,  96 
corsets.  95,  97 
corset,  plaster,  95 
Phelps',  98 
Weigel's,  98 
plaster  corset,  95 
plaster  jacket,  82 

application    to    pa- 
tients who  ha"V"e 
been   treated    on 
stretcher  frames, 
94 
modifications  of,  97 
in   recumbency,  91 
Taylor  brace,  76,  79 

head  support,  82 
Thomas  collar,  98 
Bradford  frame  in,  69 

modifications   of,    69, 
70 
general  principles  of,  67 
horizontal    fixation    in, 

68 
Lorenz's  apparatus  in,  68 
Phelps'  bed  in,  68 
principles    of,    in    their 
practical  application, 
98 
wire  cuirasse  in,  69 
in  upper  region,  58 
abscess  in,  59 
attitude  in,  58 
symptoms  of,  58 
weakness  in,  28 
of  tarsus,  458 

distribution   of,    to   individual 
bpnes,  458 

statistics  of,  458 
treatment  of,  459 
of  wrist-joint,  474 

age  at  incipiency  of,  475 

statistics  of,  475 
prognosis  in,  475 
statistics  of,  474 
symptoms  of,  475 
treatment  of,  475 
tenosynovitis  at  ankle-joint,  464 
Typhoid  spine,  132 
treatment  of,  132 


U 


UxiLATERAi^  dislocation  ut  hip-joint, 
251 
knock-knee,  580 


Vertebr.e,  absence  of,  231 
^'ertebral  column,  stiffness  of,  133 
^'olkmann  seat  in  treatment  of  lateral 
curvature  of  spine,  221 


W 

Weak  ankles  in  childhood,  694 
foot,  679 

in  childhood,  694 

deformity  of  legs  with,  695 
general  weakness  in,  696 
irregular  forms  of,  695 
outgroAAai  joints  in,  695 
out -toeing  and  in-toeing  in,  694 
symptoms  of,  694 
weak  ankles  in,  694 
deformity  in,  679 
diagnosis  of,  687 
etiology  of,  683 
extreme  types  of,  692 

persistent  abduction,  692 
pes  planus,  692 
limitation  of  motion  and  muscu- 
lar spasm  in,  692 
pathology  of,  683 
rigid,  706 

functional  use  in  overcorrected 

attitude  in,  70S 
treatment  of,  706 
adjuncts  in,  713 
forcible     overcorrection    in, 

707 
opei'ative,  714 
plaster  strapping  in,  713 
systematic  manipulations  in, 

709 
Thomas',  713 
varieties  of,  712 
symptoms  of,  685 
treatment  of,  697 
attitudes  in,  699 
brace  in,  703 

construction  of,  701 
positive  action  of,  704 
exercises  in,  699 
raising  inner  border  of  shoe  in, 

699 
the  shoe  in,  098 
support  in,  700 
A'arieties  of,  691 
Weakness  of  anterior  metatarsal  arch, 

721 
Webbed  finger,  495 
etiology  of,  495 
treatnient  of,  495 
Whitman's    operation    for    acquired 

talipes  calcaneus,  828 
Willett's  operation  for  acquired  talipes 

calcaneus,  826 
Wolff's  law  of  functional  pathogenesis 
of  deformity,  238 


JSDEX 


871 


Wolff's  treatment  of  knock-knee.  589 
Wrenches  in  treatment  of  neglected 

talipes,  794 
Wrist,  defomiities  of,  congenital,  491 
-joint,  tenosynovitis  at,_acute,  480 
tuberculous  disease  of,  474_^ 
age  at  incipiency  of,  475 

statistics  of,  475 
prognosis  in,  475 
statistics  of,  474 
s3Tnptoms  of,  475 
treatment  of,  475 
sprain  of,  480 


Wrist,  sprain  of,  chronic,  480 
suljluxation  of,  490 

etiology  of,  491 

spontaneous,  490 

treatment  of,  491 
Wrjiieck,  642.     See  Torticollis. 


X-RAVS  as  accessory  in  treatment  of 
tuberculous  disease  of  knee-joint, 
424 


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